 Good afternoon, everyone, and thank you for joining our webinar today. Welcome to my office. This is my office at the Breast Center at Bayshore Medical Center. I'm so excited to be with you today. As Kaylin said, I'm Dr. Harriet Borowski, and I'm honored to serve as medical director of Breast Imaging both at Bayshore Medical Center and at Riverview Medical Center. This is my dream job, and I am so pleased to work with my really talented colleagues, including Dr. D'Angelo, who I'm sure many of you know, and Dr. Sokolovskaya. Of course, it's October, and it's Breast Cancer Awareness Month, and I am certain it doesn't need to be October for all of us, everyone who's on this webinar. I know Breast Cancer has touched our lives in one way or another because it is so common. I'm so pleased to be discussing with you what has been my professional passion for the past two decades, and that's early detection and diagnosis of breast cancer. During today's talk, I'm going to share with you what I have learned about breast cancer and what I think are the most important things that you need to know about breast cancer that could possibly save your life or that of your friend or family member. So we're going to talk about why we screen for breast cancer, who should be screened, when and how often, what imaging modalities are best, and where to be screened for breast cancer. We all know breast cancer knows no racial, ethnic, socioeconomic, or political divides. It is the most frequently diagnosed cancer in women with about 2 million cases, new cases per year worldwide. Nearly 290,000 cases in the United States per year. Think about that number. It's a big number, and what about those of us that are so blessed to live in the state of New Jersey? Nearly 8,500 new cases per year, and it is just an all too common and significant cause of deaths with nearly 40,000 per year in the United States and about 1200 per year in our state of New Jersey. And these are the most recent statistics from the American Cancer Society showing estimated cancers. And I have to say for the past number of years, breast cancer has surpassed prostate cancer, but in 2022, prostate cancer is the most common malignancy, and breast cancer is right behind it. However, in the United States, breast cancer, new cases, and these are new diagnosis of cancer, is more frequent than prostate cancer, generally speaking. And it is the second leading cause of cancer death in women after lung cancer. And you may or may not know that the state of New Jersey is a hot spot. It is in the top 10 states of hot spots for breast cancer. As you can see on the East Coast, there is New Jersey, Delaware, Connecticut, New Hampshire, North Carolina, and then mid states. And it is a hot spot. No one knows why these states and Hawaii is also a hot spot for breast cancer incidents for reasons that we don't know. What about counties? We live in Mommeth County, and you can see sort of the deeper shades are the more populated areas that have the highest incidence of breast cancer. Mommeth County is up there, but for whatever reason, Hunterton County has the highest incidence in the state of New Jersey. And after I'm finished talking, if anyone has any ideas about why this might be, certainly share it. I'm relatively new to the state of New Jersey. So let us know. Here's the good news about breast cancer. Out of all of the cancers we can get, it is highly curable, especially when it's found early. As you can see from this graph, when breast cancer is localized to the breast, as it is in 62 percent of cases, and this exactly corresponds to about the number of women in the United States that gets screened. It's about 62 to 65 percent. So we all need to increase that number, and we all can by getting the word out. That's why I'm here with you today. When breast cancer is localized to the breast, look at the five-year survival rate. It's 99 percent. When it's regional, and that means involving lymph nodes on that side, as it is in 30 percent of the cases, the five-year survival rate goes down, but it's 86 percent. And when it is diagnosed at a stage when it is metastatic, that means spread to other parts of the body beyond the axillary or underarm lymph nodes, as it is in six percent of cases, the five-year survival rate is much lower. It's 27 percent, and that's why I'm here today to tell you about the importance of screening. So if you look at the incidence of breast cancer, and this is in the United States, divided into racial and ethnic people, you can see that white women in the United States have the highest incidence of breast cancer. Black women are second, and then you can see American Indian, Alaska Native, Asian, Pacific Islands, or in Hispanic are all going down the line. And then the hotter pink shades are the death rates from breast cancer. And here you can see a difference. Black women in the United States have the highest death rates from breast cancer, and we're going to talk about that as I share some other statistics with you. So that's in the United States. What about in the state of New Jersey? You can see it's very similar. White women have the highest incidence, followed by Black women, been followed by Hispanic women, and then Asian and Pacific Islanders. And again, look at the death rates. You can see that Black women in the state of New Jersey have higher death rates from breast cancer. One of the reasons, as I just showed you, stage is so important. Stage at which breast cancer is diagnosed has a very direct impact on prognosis and survival. And if you look at Black women compared to white women, you can see, and the stages are the less deep shades of pink. Black women are diagnosed at higher stages when there are regional lymph nodes involved, 31% compared to 24 and 27, 29, and 31% among Hispanic women. And then greater percentage of women diagnosed with distant metastatic disease. So we're seeing more advanced stage breast cancers generally in Black women compared to other racial and ethnic groups. And then what about the types of breast cancer? Because there are many different types, including those that are more aggressive. And again, if you look at Black women compared to other racial and ethnic groups, you can see that they tend to be diagnosed with breast cancers that we consider to be more aggressive. Those are breast cancers that express something called the HER2 oncogene, and those are breast cancers that are triple negative. So that all contributes to the difference in death rates. When we talk about breast cancer, we tend to talk about breast cancer as if it is one disease. And actually it's very many different diseases presenting at different stages. And so you really can't compare one woman's experience to another's because there are so many different types and subtypes, whether breast cancer starts in our ducts, which lead toward the nipple or lobules where milk is produced when we're breastfeeding, whether breast cancer is invasive, as it is most of the time 75% of cases versus in situ just in the ducts, which is stage zero, which it is about 25% of the time. How aggressive the cells look under the microscope generally there's three grades, grade one least aggressive, grade three most aggressive, and then the specific genetic traits of the tumor itself, not the person, accounts for different types of breast cancers, whether the tumor expresses an estrogen or progesterone receptor and whether or not it expresses the HER2 oncogene, and all of these things inform individualized, personalized, and targeted treatments. So why do we screen for breast cancer? Well, we screen for breast cancer, as I told you, because it is so common, because it is progressive. So screening is an opportunity to halt the natural progression of the disease. And it's an opportunity, of course, to save lives. That's why we screen. We're screening to test a population of healthy women in order to find unsuspected breast cancer in smaller sizes and earlier stages than would otherwise be found, for example, if you have a lung. Who should be screened for breast cancer? So I'll share with everyone that I do hear women quite frequently when I'm seeing them at our centers every day, who are a little bit rolling their eyes. I don't know why my doctor sent me for a mammogram. There is no family history of breast cancer. Well, I'll share with you about 75 to 80% of all women diagnosed with breast cancer have no family history. The two main risk factors are having breasts, being a woman, and getting older. And that's something that all of us are experiencing together. And you can see by this graph, as we age, particularly at the time of about 35 and on, the number of breast cancers increases up until about the age of 75. So all of us, just by being women, have a lifetime risk of getting breast cancer of about 14%. And that's one in seven women. But some women are what we call at elevated or high risk for breast cancer. Those are women who themselves have had a personal history of breast cancer. You can see they're at three to four times higher risk of getting another breast cancer. Those women that have a relative with breast cancer, especially a first degree relative, especially if there's more than one first degree relative, and if there is a male relative with breast cancer. And I want to share with everyone because it is sort of a myth or a misperception that only the mother side of the family is important for breast cancer risk. That is not true. Your father side of the family and the DNA you get from your father is equally important from the DNA you get from your mother in terms of breast cancer risk and almost everything. Dense breast tissue, that's the type or the composition of tissue under the skin. It's different in all of us. Memograms are sort of like a thumbprint. I know some women just from their mammogram. Having more fibrous dense breast tissue for reasons that we do not know is an independent and significant risk factor for breast cancer. Those of us that have more fibrous tissue and I'm one of them are at higher risk than our girlfriends who have fattier tissue and it's significant. If you have a prior biopsy showing atypical ductal hyperplasia or any atypia or lobular neoplasia, you're at higher risk for getting breast cancer. Some women had Hodgkin's disease. It's a certain type of lymphoma and they had chest radiation back in very many years ago. Children were radiated who had enlarged thymus tissue and that creates a markedly elevated risk for breast cancer down the road. When you get older and of course if you've inherited certain genetic mutations, the most well known are the BRCA1 and BRCA2 mutations, though there are others, you're at significantly higher risk for getting breast cancer. Then there are associations that I sort of think of in terms of our hormonal milieu. It is felt that perhaps the proliferative changes that we go through just in our normal cycles may predispose breast cancer due to DNA mutations and cellular proliferation. If you started having your period early and you have menopause late, you've had more ovulatory cycles and therefore perhaps an opportunity for a breast cancer to develop from a DNA mutation. Also, if you've had no children, we know when we have children we don't have her period for nine months and if we breastfeed that also creates a lag for a halt to our periods during that time. If you're on hormonal therapy, estrogen and progesterone after menopause, it doesn't necessarily cause breast cancer, but it may promote breast cancer or certainly create a hormonal environment where breast cancers are able to grow and divide and do their thing. Postmenopausal obesity is a risk factor for breast cancer and alcohol consumption as well. Thinking about prevention, I wish I could tell you we knew what causes breast cancer and we could prevent it, but there are certain decisions we can make in healthy lifestyles that can certainly perhaps decrease our risk, exercise, healthy diets, and decreasing our alcohol consumption for sure. There are computer models available to us and hopefully one that will be available in our computer system epic, our electronic health record that can actually quantify a risk. If we put in all of our ages, our reproductive history, our family history, our breast density, we can sort of get a lifetime risk for breast cancer and that can help inform personalized screening recommendations. I'll also share with you the American College of Radiology recommends that all women should have a breast cancer risk assessment by the time they are at the age of 30. Why? We want to identify those high-risk women that may need to have genetic counseling and testing and therefore start their screening at the age of 25 to 30 and some women, particularly who have first-degree relatives that had breast cancer at young ages may need to actually start screening by the age of 30. So talk to your primary care physician and gynecologist about a risk assessment. So despite all the new technologies and everything we've heard about breast cancer, the single most important screening test, the one that's tried and true and is the primary imaging modality and proven to reduce deaths from breast cancer remain a mammogram. But in this day and age, not just any mammogram, but all women should be having what's called a 3D mammogram or digital breast tumor synthesis, I think in the year 2022 and almost 2023. This is the current standard of care. Mammograms are relatively inexpensive, quick to perform, they are safe and well tolerated. The radiation dose is extremely low. It's similar to a radiation dose we might experience from a flight from here to Chicago. Mammograms are readily accessible to large populations of women. We start doing mammograms early in the morning at our centers at seven o'clock and at Riverview go into the early evenings. And we do mammograms on Saturdays. So we like to make it accessible to all women. Mammograms are accurate. And as I said, they're the only screening tests that have been proven to reduce deaths from breast cancer. At Bayshore, we have what I consider to be the next generation of 3D mammograms. Bayshore has the most advanced 3D mammography unit. It has a more comfortable curved paddle. We all know what it's like to be under that compression. It is quite uncomfortable for some women more than others, but it's brief. So this curved compression paddle, and you can see it right here, just makes it a little bit less uncomfortable. Most importantly, from my perspective, being the breast imager or breast radiologist, the images are the highest resolution that are currently available. The proof of benefit from mammograms are not one, not two, not three, but seven randomized control trials. This is considered the gold standard for proof of benefit showed that women invited to be screened compared to women not invited to be screened. And these were trials that were done in the 1960s, 70s, and 80s, showed that there was a reduction in breast cancer deaths. And the women who were invited to be screened by 25 to 52%, and that's felt to be an underestimate. And we know that since we have developed screening programs in the 1990s, death rates from breast cancer have decreased by 40%. And certainly early detection has led to an enormous paradigm shift in how we treat breast cancer. Because most cancers are early stage lymph node negative small tumors, which have de-escalated the type of surgery, type of radiation therapy, and many women no longer need to have chemotherapy. Of course, not every screening test is perfect. And I do want to share with you, having a negative mammogram does not mean you don't have breast cancer. It means breast cancer was not detected. And mammograms alone may not detect a breast cancer in about 6 to 10% of the time. It's higher in women who really have fibrous dense breast tissue. Mammograms may miss 20 to 30% of breast cancers in women who have dense breast tissue. And that's 50% of us. And those cancers that are not detected tend to be more aggressive, which is why seeing your doctor and having a breast exam and never ignoring a lump is really important. What are the current screening guidelines? It's a little bit complicated and confusing because our governing bodies, the different medical groups, and societies have different screening recommendations. They all agree on one thing. Annual screening mammograms save the most lives. It is just that what has been factored in in the screening recommendations include the anxiety by being recalled. Most of the time when we recall women for extra images, everything turns out to be okay. And even when we do biopsies, about 80% of the time the results are benign. If you factor in that stress and anxiety by what are called false positives, then if you screen less frequently, you'll decrease that stress, that anxiety that is due to false positives. And that is why different organizations have different screening guidelines. We feel we can help women with that stress and anxiety by giving them the results, doing biopsies quickly, minimally invasive biopsies. And so the American College of Radiology, the National Comprehensive Cancer Network, Society of Breast Imaging, American College of Gynecologists, and the American Society of Breast Surgeons recommend annual mammograms 40 and above. And when should you stop having mammograms? Well, mammograms are for healthy, vibrant women who have a life expectancy of at least 10 years. I'm certain that's everyone who's on the webinar today. If you have a first degree relative who had breast cancer, premenopausal, you want to start screening 10 years earlier than the age at which they were diagnosed. And certain high-risk women and those women with dense breast tissue should consider having what we call supplemental breast imaging, which could be a mammogram and an ultrasound or a mammogram and an ultrasound and an MRI in six months. That is why when you receive your mammogram results, you are notified if you have dense breast tissue that is a New Jersey state law that informs women that you have dense breast tissue. Therefore, you're at elevated risk. And there's a greater chance that mammograms might not show everything. And that's why we do additional imaging. So if you're curious about what it looks like to have dense breast tissue, here are the four categories from fatty tissue. This is the type of tissue under the skin that creates a dark, very see-through pattern. We're going to step up to those women who have average density breast tissue under the skin. There is some white areas, but again, it's mostly dark tissue, which is the fatty tissue to category C, which is heterogeneously dense. You can start to see there is more whiter tissue in the mammogram. And then our fourth category by RADS D, which are women who have extremely dense breast tissue. So just to give you a sense of the heterogeneity of how a mammogram looks and what the type of tissue can look like. So what do we use for supplemental imaging? Well, one imaging modality that I'm sure many of us have had, not just for our breasts, perhaps when we were pregnant or abdomens is ultrasound. That uses sound waves. It's easy to perform. It's very well tolerated. It's safe. It provides cross-sectional imaging, and it's not impeded by our breast density. We can see well through most women who have dense breasts. And the indications for having a screening breast ultrasound is for women who are at average risk and have dense breast tissue or intermediate and high risk as well. And this is just an example of a 57-year-old patient of mine with a family history of breast cancer. Because I've taught you well, you can see that this is a woman who has heterogeneously dense breast tissue. There's a lot of whiteness in the pattern. And ultrasound detected this very small irregularity in the tissue. And this was a very small curable invasive ductile cancer. What about MRI? MRIs of the breast are done with contrast. Many of you have heard of MRIs of the brain, the joints, the spine. We do MRIs of the breast. We have a special table. You lay down on the table. There is an IV started in your arm, because what we're looking for is areas in the breast that have an increased blood flow and leaky vessels. So what MRI gives us that we don't get with a mammogram and ultrasound is this functional information about what areas in the breast have abnormal blood flow, because we know that the most impressive type of tumors, the very first thing they need to do is bring in a blood supply. And they have abnormal increased vessels. And so MRI gives us this unique very high-resolution soft tissue detail information that we don't get from a mammogram and ultrasound. Who should get annual MRIs for screening purposes? Well, there are specific guidelines. This is specifically for high-risk women who have a lifetime risk based on a model of greater than or equal to 20 percent. These are often women who have dense breast tissue and at least one first-degree relative. Those women who have known genetic mutations that predispose them for breast cancer, the most well-known are the BRCA1 and BRCA2, not just them, but their untested first-degree relatives. Other known mutations that are associated with breast cancer, those women should have MRIs in addition to their mammograms once a year. If there is a history of chest radiation, mostly for young women who had Hodgkin's disease between the ages of 10 and 30, they should have MRIs once a year. And if you have a personal history of breast cancer and you have dense breast tissue or you were diagnosed at or before the age of 50, we recommend MRIs once a year. And here's an example of an MRI in a patient of mine who had a known BRCA2 mutation. She had a normal mammogram. And this is what it looks like when an area in the breast has an abnormal blood flow and leaky vessels, they show up like very, very bright spots. They are easy to see. And this was a small invasive ductile cancer. There is a new technology that we are going to be implementing soon, which is called contrast-enhanced mammography. So I just shared with you that contrast that we give through the vein can give us functional information about blood flow and leaky vessels. What if we combine the high resolution images of the 3D mammogram with contrast? Well, this technology is FDA approved. It is being utilized at many breast centers across the country and in Europe. We are hoping to implement this soon. And that combines the mammogram with contrast. And I'll show you what that looks like. It's a subtraction image. We give contrast while a woman is sitting in the mammography room and she gets a mammogram after contrast at a low energy and then high energy. And the subtraction of the two shows us anything in the breast, which is enhancing. And this is what the contrast-enhanced mammogram looks like. And it's sort of a way to get that functional information. And yet, as you know, not having MRI. MRIs are very expensive. They can be uncomfortable. They're about a 35 to 40 minute exam you're laying on the table. And so this is sort of an alternative for certain women to get that information that contrast can give us. So a lot of information I've given you. Where you have your mammogram could be the most important thing I say today matters. Just like, you know, where you put your trust in care is so, so important. And lots of orthopedic surgeons, fixed bones, do joints, do everything. But if you need a knee replacement, you probably want to go to an orthopedic surgeon who specialized in knees. Well, it's the same thing about your mammogram. You want to have your mammogram at an ACR accredited breast imaging center of excellence. Why? Those are centers that are officially accredited. They're not just saying they're good. They have been inspected and they're accredited in the areas of mammography, breast biopsy, tumble synthesis guided biopsies, ultrasounds and MRIs. And that means that they go through an inspection process. A physicist has to sign off on all of these modalities. They have to have the most experienced technologists and physicians. And that's just for your own personal safety. You want to go to their forest center that has dedicated physicians and technologists. That's all they do. And so they have a very high level of expertise and experience in breast imaging. You want to go to a place where you have access to multi modality screening that I just shared with you. Minimally invasive breast biopsies and also where if you are diagnosed with breast cancer, we've got a multi disciplinary team of highly experienced breast surgeons, breast oncologists, radiation oncologists, genetic counselors. So you have access to all of this with most importantly continuity of care and in the hands of very compassionate people. Our team of physicians include myself, Dr. DeAngelo and Dr. Sokolovskaya. And with that, I think I'll end my talk today and find out if you have any questions, concerns, anything you want to ask me while we have this time together. Thank you. Thank you, Dr. Barofsky. Very informative. Somebody had asked and I know that you kind of covered it or you did cover it, but they may have missed. Does Hackensack have these mammograms services? Absolutely. Hackensack has all of the services, Bayshore Medical Center, Riverview Medical Center, where I am the medical director, has all of the services that I described to you today, including minimally invasive breast biopsies that we do under ultrasound guidance, 3D guidance and MRI guidance and most of the centers at Hackensack Meridian Health do. I'm not familiar probably with all of them, but most of them certainly the larger centers. Another question here is, are mammograms safe for breastfeeding person? I'm 35 and I have never checked my breasts. I don't have breast cancer in my family history. I also don't have any symptoms, but should I wait until the end of breastfeeding? If you're 35 and you're breastfeeding and there is no family history, I would wait to have your baseline mammogram until after you've completed breastfeeding, but your question is such an important one. Women who are of screening age, who are breastfeeding, can certainly have a mammogram. As you know, when you're breastfeeding, the breasts are very enlarged. They are often engorged, but in high-risk women, we still continues. It is safe to have a mammogram when you're breastfeeding. It is still better than no mammogram when we usually combine a mammogram with an ultrasound. If you are breastfeeding and you are of screening age or you're high-risk, we still do mammograms in women who are breastfeeding. If you're 35 and you have no family history and you're breastfeeding, you can put it off until you have completed your breastfeeding and guideline for starting screening is the age of 40. Any other questions or is there anything I didn't touch upon? Another question came in, what are calcifications in a breast? Calcifications in the breasts are very, very common. I also should tell you that we do mammograms, of course, to screen for breast cancer, but guess what? We find all sorts of things, most of which are not cancer. One of the most common things we find and we call you back for extra views and we do biopsies of are calcifications. Here's our dilemma. Our breasts are very proliferative throughout our lives. There are so many changes that go on normally and calcifications in our depths are most often in normal finding. I see calcifications on mammograms more often than I don't. Here's the dilemma. Breast cancers and even pre-cancerous changes tend to form calcifications. That is why mammograms are so good at early detection. I would say about 80% of breast cancers form calcifications. If you have a mammogram and we find calcifications that are grouped or hanging out together or have increased in number, we always do magnification views to see them better. If we have any concern about them, the only way to know for sure is to take a biopsy. Having calcifications in your breast does not mean you have breast cancer. They're very common. I have them on mine and most women on this webinar also have calcifications, but they can be a reason that you need extra views and perhaps need a biopsy. They can sometimes be indicative of pre-cancerous changes and cancerous changes in the breast. Another question we have, does having larger breasts make it more difficult to detect cancer? Having larger breasts and a complex mammogram pattern and dense breast tissue does because it can mask breast cancers hiding in there. It's not necessarily the size. It's really the complexity of the pattern, but the larger size may make it difficult for ultrasound alone to really penetrate through all of that dense breast tissue. Mammograms will be inclusive of the breast tissue, but sometimes not of everything, just so you know. Most of the organs in our body are encapsulated and have a top, bottom, side to side. You can tell where the organ stops and ends just so you know breast tissue is not like that. Breast tissue can sometimes extend to the sternum, the bone in the center of our breast. Breast tissue can extend up into our armpit, down into what's called the inframammary fold, and mammograms alone may not detect or include, I should say, all of the breast tissue, particularly women who have larger breasts or have breast tissue under their arms. That's why you want to go to a really good center with wonderful technologies to make sure all that tissue is included, but larger women who have larger and dense breast tissue, it may be harder to detect breast cancer with mammograms alone. Another question is, are there any discounts or for uninsured women paying out of pocket for a mammogram? So we do have a program, the foundation has a program for uninsured women to come and have mammograms. So please call, I'm glad our phone numbers are here, call Bayshore, call Riverview Medical Center if you don't have insurance, and you need to have a mammogram. The foundation has funds for that, and I believe it's called the pink fund, Kailin, or does anyone on the line have any other information, but give us a call because we can support you, both of our foundations at Bayshore and Riverview have funds to support, not just the screening mammogram, but anything else that might be needed. Thank you for that. And actually, excuse me, for the anonymous question, if you'd like to send another anonymous message with your email address, I can send that over to you for additional information. And that leads me to share one other important bit of information to share everyone together today. And that is, in the state of New Jersey, you don't need to have a doctor's prescription to have a mammogram because mammograms are screening tests that can be lifesaving. We don't want to have any obstacles or create disparities in care. We all know some people maybe don't have insurance or, for that reason, don't have a regular doctor or sometimes you call your doctor for an appointment and you can get in in six months. Well, you're already two years behind on your mammogram because of COVID or for whatever reason, you can have a mammogram without a doctor's prescription. So we don't want to have any obstacles for you calling in and scheduling that appointment. Great point. I was actually going to bring that up as well, Dr. Barofsky. And we do have somebody on our foundation that just confirmed that, yes, it's called the pink fund and it is 100% funded by donations. So as Dr. Barofsky mentioned, feel free to reach out and we'll definitely get you scheduled for your screening mammogram. There's another question here. Is it possible that dense breasts last year will not be the case for this year's mammogram or should ultrasounds be the standard procedure? So glad you asked that question. That reminds me to share with everyone that how dense or fibrous the tissue is or really the breast composition for that matter, believe it or not, is a genetic trait that we inherit either from our mother or father side of the family. Generally speaking, particularly the breast tissue that is the densest since it is a genetic trait, it's pretty constant throughout a woman's life. If your breast density changes from one year to the next, there may be a couple reasons that that can happen. Number one, weight gain. When women gain weight, it generally is under the skin in the subcutaneous tissues. Guess what? Our breasts are skin appendages. They're highly specialized skin appendages. So when we gain weight, fat is deposited under the skin and in the breast. And actually it can make the breast look less dense. And conversely, when we lose weight, there can be an increase in breast density. After we go through menopause, because there are hormonal influences for breast density, there can be what we call fatty involuntial changes where some fatty tissue creeps in. And so you can be heterogeneously dense one year. And then over the course of the years, you can change your density to average. So that can be a reason that the breast density has changed. And also, and I'll be honest with you, the breast density is somewhat subjective. There are four categories of breast density, fatty, average, heterogeneously dense and extremely dense. And I can tell you as someone who reads mammograms every day of her professional career, there's everything in between. So because it's subjective, one doctor might decide your density is average and to another doctor that that looks heterogeneously dense. So that can be a reason that there's a different density in your mammogram report. And that's probably because you're in between the two. Another question. If you don't need a prescription, why has Riverview told me I can't schedule my mammogram without one? So that shouldn't be happening anymore. It was traditionally that way. And we have evolved a process so that we can do screening mammograms without a doctor's prescription safely. The most important thing, if there isn't a doctor's order, we have to assure and take it upon ourselves that appropriate follow up is given. So we need to make sure that women who came in without a doctor gets her results. And we have to make sure if the mammogram is abnormal, we have a way to inform her and make sure she schedules an appointment to come back in. And so we send out certified letters. But it is relatively new that we are accepting women for screening mammograms without a prescription. It's been about a year. So if you get that information that you can't have a mammogram without a prescription or you get sent out the door because you've left your prescription at home, certainly let everyone know that you've been told otherwise. Or give us a call. Ask to speak to Dr. Borowski.