 Hello and welcome to today's noon conference co-presented by MRN Line and AAWR. The AAWR was founded in 1981 to provide a forum for issues unique to women in radiology, radiation oncology, and related professions. The Association sponsors programs that promote opportunities for women and facilitates networking among members and other professionals. As well, AAWR strives to meet the diverse and changing needs of its members through mentorship opportunities for the next generation of women radiologists. You can learn more about their mission and membership at AAWR.org. We're thrilled to partner with AAWR in these lectures as part of our shared commitment to advancing and supporting women in radiology and transforming the way radiologists learn and thrive. Today, we are honored to welcome Dr. Elizabeth Kagan-Arlio for a lecture entitled, In Preparation for Women's History Month, Screening Memography Saves Lives. Dr. Arlio completed her diagnostic radiology residency and breast body fellowship at Wild Cornell Medicine in New York City, where she's been on staff since 2010. She's currently a professor of radiology there and also serves as editor-in-chief of the Radiology Journal Clinical Imaging. At the end of the lecture, please join her in a Q&A session, where she'll address questions you may have on today's topic. Please remember to use the Q&A feature to submit your questions, so we can get to as many as we can before our time is up. With that, we're ready to begin today's lecture. Dr. Arlio, please take it from here. Hello, thank you for that introduction, and thank you, everyone who's joining us for convening for this noon conference about screening mammography in light of upcoming Women's History Month starting tomorrow. As mentioned, I'm Elizabeth Arlio, professor of radiology at Cornell, where I practice breast and body imaging, and I am also required to disclose to you that I'm editor-in-chief of the Radiology Journal Clinical Imaging. You know, October in certain circles, certainly in radiology and breast imaging and women's health is obviously all well known to us as Breast Cancer Awareness Month and currently for one more extra day on the sleep year we are in February, Black History Month, and as we look forward to tomorrow, to March, it will be Women's History Month. And to tie this in with today's lecture topic of screening mammography, there are actually so many women who have made history, who have also had breast cancer, including those listed here. And seeing all these known names and faces, I think this reminds us, it certainly reminds me, that as we get ready to celebrate Women's History Month, to maybe also remember to celebrate screening mammography because, you know, while it's far from perfect, it is still the best test we currently have to save lives from premature premature death from breast cancer. And so with this in mind, let's turn to thinking about, will it be helpful to take a step back and think, you know, a step back from the daily grind of the work station, all the lists we have to cover to remind ourselves, you know, why we screen, why there are so many different guidelines, and putting the risks and perspectives for ourselves and also our patients and providers, because not only in October breast cancer Awareness Month, but also potentially in Women's History Month, may we get more questions about this. Or really any day, it's good to be armed with it. So, you know, first it's important to keep in mind that the benefits of screening mammography include, but are not limited to significant decrease in breast cancer specific mortality. This is really important to keep in mind, and you know, the words why we screen, because to quote this 2021 JACR article about women at average risk for breast cancer, written by a number of colleagues and friends from the ACR Breast Cancer Screening Leader group, I'm going to quote this article because I couldn't, you know, say it better myself. So quote, the ACR and SBI recommend annual mammography screening beginning at 40, which provides the greatest mortality reduction, diagnosis at an earlier stage, better surgical options, and more effective chemotherapy. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced stage tumor, and women who wish to maximize benefit will choose annual screening starting at 40 years old and will not stop screening. Amen. So, the ACR SBI recommends annual screening starting at 40 and has done so for many years because of diverse scientific evidence supporting this, including considering each one one by one in brief, the randomized controlled trials, national population based data, computer modeling, and international service screening data. So, this slide shows a forest plot from a Lancet meta analysis of every single randomized trial ever done studying screening mammography, demonstrating that the relative risk of breast cancer death in women invited to participate in screening was 0.8 or 20% lower than women not invited to participate in screening overall. Even, number one, including the flawed Canadian trials, which flawed in that they did a clinical breast exam before assigning to women to screening or not, so not truly randomized. Number two, even though all the randomized controlled trials were done as early as the 1960s up to the 90s, so all film, obviously no digital, obviously no Tomo, and number three, even taking into account the inherent problems of randomized controlled trials in general, including the multiple reasons listed here, the most important of which I would say are number one and two, namely non-compliance, which means that women in the custody group were are invited to have screening mammography. However, a woman refuses to be screened and dies of breast cancer, she's still counted in that screening group, which minimizes benefit in the screening arm. And in contrast, in contamination, women in the control group who are not invited to participate in screening, but if they have a screening outside the trial, they're still counted as an unscreened control, which would artificially improve the mortality benefit in the non-screening arm. Does that make sense? I hope so. That's why when we look at national population-based data, we see an even greater reduction in breast cancer specific mortality than is demonstrated by the randomized trials. In other words, as a result of the randomized trials, randomized controlled trials, screening mammography was introduced at a population-based level in the United States in the mid-1980s, and though it was not then, and is still not now, an official national screening program, within a few years, the death rate from breast cancer, which had been steady for decades, began to decrease as demonstrated on this slide. And specifically, this slide shows a 38 percent decrease in U.S. breast cancer mortality from 1990, when the breast cancer death rate was 73.8 per 100,000 women to 2014, when the breast cancer death rate was 45.9 per 2,000 women. And two additional points about this. Hong Kong doesn't screen any of their women, but has access to modern therapy, and the death rates are increasing there, in contrast to decreasing here. And however, unfortunately, number two, the surveillance epidemiology and result program organizing this population data, the SEER registry, does not make note of whether women with breast cancer were screened or not. This is obviously a major flaw, whereas data for international screening study service screening programs in other countries do have this information. And so when stratified by those who were actually screened, as opposed to just invited to screened, as in the randomized controlled child, we see an even greater benefit, an even greater reduction in breast cancer specific mortality. Well, here's this, the same graph now just extended out to 2020, just before COVID. And so what about specifically for women in their 40s? Well, if one assesses life years, a very common metric for impact of disease, this JAMA 2015 article demonstrates demonstrating the distribution of person years of life lost due to breast cancer by age at diagnosis shows that as you can see here, the peak is at age 45 to 49. And this meta analysis of the randomized control trials focusing on data for women in their 40s specifically demonstrated a statistically significant 18% mortality reduction, reduction in breast cancer specific mortality in women in its age group. For the more younger women, including women in their 40s, tend to get more aggressive, faster growing cancers, so they should definitely be screened annually starting at 40 instead of bi-annually or deferring start age to 45 or 50 as some organizations recommend, as we'll further discuss. So screening starting at 40 is further supported by meta analyses including this one based on case controlled studies from service screening data from countries as far reaching as Australia with some enrolling women in their 40s demonstrating a 49% decrease in breast cancer specific mortality in those actually screened. And while regular screening mammography results in a substantial reduction in breast cancer mortality as summarized here, again as the 2021 ACR SBI statement, you know finally really explicitly states which is why I quoted it, you know mortality reduction is not the only benefit of screening mammography and yet unfortunately the ACR and SBI are the only organizations issuing screening mammography guidelines to take these other benefits into account including morbidity reduction because screening mammography finds cancers smaller than they would be if detected clinically when palpable. Women have the option of smaller surgeries, lumpectomy instead of mastectomy and potentially avoiding the toxic effects of chemotherapy. Furthermore, the detection of high risk lesions is also an important benefit to consider because it may change how patients are managed more on the guidelines for high risk women later in this talk and finally the vast majority of women have a truly negative mammogram the vast majority of time and being reassured as such is obviously enormously beneficial as well. You know note perhaps in retrospect that I've been specifically saying breast cancer specific mortality and this is a really important distinction from quote all cause mortality which this and other articles try to use to show that screening mammography doesn't decrease mortality. So this August JAMA internal medicine article concluded that quote and this was looking at a meta-analysis of randomized controlled trials for many screening tests not just screening mammography but including screening mammography and the conclusion for all these different screening tests was quote the finding of this meta-analysis suggests that current evidence does not substantiate the claim that common cancer screening tests save lives by extending lifetime except possibly for colorectal cancer screening with sigmordoscopy. That's on my area of expertise so I'm not going to get into it here but the point I want to make is that it's futile to use all cause mortality as an endpoint especially when extrapolating from small randomized controlled trials because you must either have to follow up for way beyond the observation time or you have to have way more participants. In other words if you did screening for ages 40 to 74 and looked at all cause mortality at age 50 you would need a randomized controlled trial of a total of 1.25 million women total for both arms to show that reduction of 2.2 percent all cause mortality which only corresponds to a mild 18 percent reduction in breast cancer deaths so the conclusion should have been quote we are not able to detect changes in all cause mortality because none of the trials are powered to measure changes in all cause mortality although the sigmordoscopy trials come close and life years gained should be a better statistic but the paper this JAMA paper calculates the life time gained and in response to this JAMA article the chief scientific officer of the American Cancer Society made the important point that these cancer screening exams have never promised to prolong an individual's natural lifespan but rather to reduce premature death from cancer. In other words again fully you know determining whether cancer screening extends a life would require an extremely large clinical trial that would have to follow patients for a very long time and the trials in this newest study here weren't big enough to look at all cause mortality and the chief scientific officer said quote if a person's life expectancy at birth was 80 a cancer screening may prevent their premature death at 65 but it wouldn't necessarily mean they'd live to be 90 instead of the predicted 80. No one is saying if you do cancer screening you're going to live to 100 years old so I think that's really well said so that's why we screened which begs the question which begs a sip of water if the data are so overwhelmingly demonstrating the benefits of screening mammography then why are there so many different guidelines out there you know making it unclear for patients and ordering providers alike what to do and to quote a quote a unique leadership book that was recommended to me by one of my breast damaging colleagues at Cornell and first female chair of the American College of Radiology Board of Chancellors Dr. Geraldine McGinty she recommended this book by Brene Brown called Dare to Lead. Excellent book and I particularly like this quotation from it which is that excuse me quote clear is kind unclear is unkind so I ask you does this look clear we have three different organizations with three different start and three different stop ages and three different frequencies and as physicians we want to ordering providers and patients to make informed evidence-based decisions about their health care and not feel like they're you know randomly throwing darts to determine which guideline to follow for something as important as a vital health outcome and as I think most of us already know the ACR slash SBI as I've been saying their recommendation for years has consistently been for annual screening mammography starting at 40 which is in contra distinction to the United States preventative services task force or prevent services as some like to call it which is as of this spring as of May 2023 by annual screening of women 40 to 74 but previously since 2009 they were recommending biennial screening of women 50 to 74 and this is all also in contrast to the American Cancer Society recommendation for starting at age 45 annually but then potentially transitioning to biennial at 55 or continuing with annual and given these three different start ages 40 45 or 50 and intervals one or two years this qualifies in my opinion as unclear and thus unkind and for clarity in 2017 as described in this publication in cancer that I wrote with colleagues from the ACR breast screening leaders group including you know real giants in the field that I was fortunate to work with sickles, Hendrix, Helvi, we used sysnet computer models to compare the ACR American Cancer Society and task force recommendations at the time where sysnet is the cancer intervention and surveillance modeling network and under the auspices of the NIH which is part of the U.S. Department of Health and Human Services the National Cancer Institute has funded sysnet to develop computer models about screening including screening mammography and computer models although not without limitations as well attempt to rectify some of the shortcomings of the data previously mentioned by applying consistent starting age is and consistent screening intervals both within and across various models and in some the purpose of this study was to use sysnet breast cancer models to compare three major screening mammography recommendations for women of average breast cancer risk at the time the study was performed in 2016 slash 2017 and the principle finding was that the greatest reduction the greatest mortality reduction surprisingly is achieved with annual screening starting in 40 a nearly 40 decrease in breast cancer specific mortality associated with the ACR SBI recommendation in contrast to only a 23 decrease in breast cancer specific mortality associated with the task force recommendation of biannual screening women 50 to 74 and a 31 decrease in breast cancer specific mortality somewhere in between for the AC American Cancer Society hyran recommendation and you know presumably the May 2023 task force updated draft recommendation of screening women 40 to 74 biannually you know you know presumably their mortality reduction would no longer be as low as 23 percent but clearly it wouldn't be as high as the nearly 40 percent associated with the ACR SBI recommendation and a logical next step for research in the future would be to directly compare these recommendations ideally with updated sysnet models so given these three mortality reduction results how can three different organizations have such different recommendations in other words how do different organizations come up with different recommendations if they have access to the same sysnet data same sysnet models the same randomized control trials and the same population based data so the top reasons for this I would say are outlined here first the task force focused its data review on randomized control trials you know the rationale being that randomized control trials as we all learned in medical school you know are the gold standard for research and yet recall from this slide that the multiple reasons why the randomized control trials underestimate the benefit of screening and actual practice so part of the difference in guideline has to do with the task force focusing on limited and older data second both the american cancer society and task force only count one benefit mortality reduction and ignore all the other benefits of screening we've discussed including those listed here yet the american cancer society and task force include all the risks both positives over diagnosis all of which are non-lethal third not only that but they they being the task force in american cancer society focus on these risks and describe them as harms as we'll get into shortly and fourth you know undoubtedly there are political and economic factors here as well you know recall that from from grade school or high school you know this is relevant for 2024 election year as well you know the three branches of the US government including the legislative branch which is congress and the federal law requires congress to produce a budget each fiscal year to set spending limits very reasonable congress as we know has two arms the house and the senate the latter of which has a health education labor and pensions committee which oversees the department of health and human services which oversees the NIH which oversees the national cancer institute which funds sysnet and the senate also authorizes the agency for healthcare research and quality the AHRQ to convene the task force therefore try to put all the the arrows together if congress is required to limit spending then they are going to understandably value recommendations which are fiscally more frugal as the task force are as demonstrated by this graph from a value-based care website based on 2010 data looking at the annual cost of screening rheumography by screening strategy and demonstrating the task force recommendation of biennial screening of ages 50 to 74 not surprisingly costs significantly less on the order of billions of dollars less than the ACR SPI recommendation of annual screening rheumography and this 2010 bar showed what was going on in actual practice in 2010 right after the task force announced its 2009 updated of biennial 50 to 74 so it shows the current current in 2010 practice at the time in which screening which which screening 61 to 73 percent of women 40 to 84 was actually going on so clearly there are political and economic factors influencing organizational guideline recommendations according to a largely in part who is in charge of the organization so for the task force we looked at my tree that's congress but what about the american cancer society and in preparing for this lecture i got curious and i went down the rabbit hole looking it up and you know discovering that the american cancer society is to put their website a non-profit organization that is exempt from federal taxation as this we ensure donor's money is spent as efficiently and effectively as possible and apparently the american cancer society raises nearly all of its money through private individual donations which quote helps to ensure our independence but still the question is who is making the decisions and according to their website the society the american cancer society is governed by a single board of directors which is made up of volunteers from the both the medical and like communities and specifically the board of director is comprised of five officers and 16 directors and the board is responsible for setting policies so of course i then had to see who the officers are guess how many physicians there are one the scientific officer a hematologist oncologist from the big break up so that's it and so since we're digging deep here into organizational structure and composition because for the reason that it significantly impacts organizational policy recommendations you know for for full uh for full um digging deep what about the american college of radiology to balance it all out so in brief for completeness as you may know the acr was founded in 1923 so happy 100th birthday last year with the state admission that quote the acr is the voice of our members empowering them to service patients and society by advancing the practice and science of radiological care and so hands how many of you are acr members you know the acr is really our voice and while i can fit the whole governing board of chancellors in on one side here is top leadership from the chair to the speaker obviously all physicians all radiologists and even if i may know one breast imager uh dana dr danis smitherin who's chair for radiology at oshener and new orleans and is going to be the next i believe i got the title right chief scientific officer a ceo for the acr so so third re-emerging from from that rabbit hole and having considered why we screen and different guidelines let's now focus on putting risks into perspective but i'll take this this section pause to take another sip of water and um look to this because i think we all get a lot of questions about risk from patients and providers alike and we want to be able to sufficiently answer and address these questions so along the lines of clear is kind an important motto for me i'm also really big on clear definition of terms so if we clearly define the word harm used over and over by the task force as demonstrated on the next slide i think it's reasonable to conclude that harm is too harsh a term for most of the sequela of screening mammography and yet the original 2009 task force recommendation article moving screening mammography to biannual screening 50 to 74 uses the word harm harms or harmed a whopping 61 times specifically the harms of screening stated by the task force include those underlined here including psychological harms false positives over diagnosis and radiation exposure i would say that the top three risks of screening mammography that we get questions about from patients and providers include false positives and over diagnosis and radiation exposure so i'm going to address these one by one you'll note on this slide that i purposely use the word risk not harm because in medicine again we talk about risk benefit analyses we talk about informed consent including a discussion of risks not harms risks benefits and alternatives and verbiage is really important so taking each of these one by one starting with false positives again let's clearly define the term a false positive is a test result erroneously indicating a particular condition it's a risk of any screening test it's not unique to screening mammography and as we know in screening mammography it just means that patients you know get a buyer at zero are recalled for additional imaging evaluation a few additional mammographic images and or an ultrasound usually to make sure everything is okay or if needed close follow-up or a biopsy all of which is certainly anxiety provoking but none of which i think it's fair to say can compare to the anxiety of dying for breast cancer as this cartoon suggests instead as this acr infographic demonstrates out of every 100 women who get a screening mammogram 90 will be told their mammograms are normal only 10 will be asked to return for additional mammograms or ultrasound of which six will be reassured everything is normal two will be asked to return in six months for a follow-up that's our biorets three and two will be recommended to have a needle biopsy biorets four or five it's shown another way a larger you know population based level for every a thousand women who have screening mammography only a hundred will return for a additional mammogram or ultrasound due to something seen on the screen 61 out of the thousand will have additional imaging and find nothing is wrong 20 will find i will have found that you know whatever the finding was was probably benign and be asked to return in six months for short interval follow-up 19 will be recommended for needle biopsy and five will be out of that a thousand will be diagnosed with breast cancer with that five being somewhere in the two to 10 per 1000 screenings range which is the our performance benchmark for cancer detection and screening mammography where within that there is the range depends on whether it's an incidence or prevalence ground to get even more granular this a j a j r article which draws on data from the tasks forest publication has quantified the risk of a false positive mammogram to be once every 10.2 years for a women in her 40s and once in once in every 16.8 years for women in her 80s so if a woman has annual screening mammography starting when she's 40 and continuing for as long as she's in good health this means she may be recalled from screening three to four times in her life and to adjust the risk of radiation exposure which is certainly a concern we hear from patients on a regular basis as well the risk of a fatal radiation induced breast cancer due to screening mammography is estimated to be once in 76,000 to 97,000 for women in their 40s and once in too many years to estimate for women 80 or older. Next is over diagnosis so again let's clearly define the term over diagnosis is diagnosis of a disease by screening that would not have become symptomatic in a patient's lifetime or cause the death of the patient and first like over like false positives over diagnosis is not unique to screening mammography it's a risk of any screening test second over diagnosis cannot as you would imagine from this definition be measured directly leading to uncertainty regarding how frequently it occurs and a lack of consensus regarding how to estimate the magnitude third by limiting screening by delaying age of onset and or increasing the screening intervals will not impact over diagnosis and this is a very important and complex idea and this last idea was the motivation for this study which I conducted with colleagues from the ACR commission for breast imaging in which we surveyed fellows of the Society of Breast Imaging asking about biopsy-proven breast cancer that didn't receive any treatment for whatever reasons and though natural history and what we found was that not surprisingly among nearly 500 untreated breast cancers detected on screening mammography non-spontaneously disappeared or regressed and an unknown percentage of these cancers could be over diagnosis in other words the indolent cancers that wouldn't go on to kill the patient represent clinically in their lifetime but because all untreated screen detective cancers were visible and still suspicious from malignancy at the next mammographic evaluation delaying the onset of screening or increasing the screening intervals between screening should not reduce the frequency of over diagnosis and this is an important concept I feel like that not that many people understand you know it stayed another way including the task force if a woman starts screening at age 40 and overdiagnose lesion could be detected and over treated when she's 40 however if this woman instead starts screening at 50 that same over diagnosis lesion will still be visible and will still be detected and still be over treated when she's 50 alternatively she doesn't have an indolent cancer and she didn't have a screen 40 she might be dead of the disease by 50 so this is why limiting screening by delaying age of onset to sound like a broken record or increasing screening intervals is not going to over and not going to impact over diagnosis but you know patients by ask or you may ask what about you know all the claims we hear that a high percentage of breast cancers are overdiagnosed and unfortunately articles such as this one by Blyre and Welch in the New England Journal of Medicine now over a decade a decade ago can substantially impact public and sometimes medical perception with its erroneous claims of substantial over diagnosis accounting as this article claims for nearly a third of all newly diagnosed breast cancer and this New England Journal medical article is one such example of medical literature you know which is not scientifically thought and I'd like to show this a newspaper clipping in the at this era of alternative facts and both truths to make the obvious point that you shouldn't just blindly believe everything you read there is disagreement over the extent of over diagnosis in breast cancer screening for sure but the case for high rates of over diagnosis rests on analyses such as these by Blyre and Welch that were biased by lead time and erroneous incidence trends and one properly analyzed data from both randomized control trials and service screening studies retrospectively respectively excuse me indicate that the rate of over over diagnosis of screening mammography is more like 10% or less and here are just two reputable studies showing this decade after decade including this article from Paletian colleagues from 2012 looking at European service screening data with scientifically valid literature concluding that the most plausible estimates of over diagnosis range from 1 to 10% and this is a more recent article in radiology in 2017 by Dr. Hendricks looking at US data also reporting a sub 10% over diagnosis rate and circling back to the earlier discussion about harms I would say that the real harm is if women don't get screened because of concerns about false positives or diagnosis because then they run the risk of under diagnosis which can be fatal to that point at my institution at Wild Cornell we've also published a study looking back on all screening mammograms 2014 to 2016 with the primary endpoint of determining the rate of detection of breast cancer and associated prognostic factors in women 40 to 44 and 45 to 49 years old and what we found was that women 40 to 49 years old had overall an 18.8% were actually 18.8% all the screen detected breast cancers that we were seeing and the two cohorts 40 to 44 and 44 to 49 had similar incidences of breast of screen detected breast cancer 8.9 and 9.8% respectively and cancer detection rates within performance benchmark standing standards supporting a similar recommendation for both cohorts and the ACR recommendation of annual screening starting at 40 furthermore over 60% of the cancers in this 40s cohort were invasive so clinically significant disease so if we didn't screen women in their 40s we'd be missing about 20% of our cancers which again would be significant under diagnosis on the other side of the age span you know in news about over diagnosis this is an article again from august of 2023 in the annals of internal medicine this article is from Yale my alma mater it's about screening mammography so i was curious to see you know if anyone in that division wrote it because i know people that division more i guess next than after a Cornell and in fact no one none of these names were familiar at all so when i looked at the authors because i wasn't even remotely familiar with any of their names it turns out that they come from the section of general internal medicine and the Yale cancer and research center obviously of international reputation but again not with not a single breast imager involved and i say you know again for this too because if you look at the composition of the task force its members again are from multiple disciplines but not a single one as a radiologist and the other thing of note here is that its conclusion also uses note the biased word harms stating that quote over diagnosis may be common among older women who are diagnosed with breast cancer after screening and it's really in contraindication in contraindication to our experience in clinical practice again at Cornell where we also reviewed screening mammography exams at our institution from 2007 to 2013 with the primary endpoint of determining the incidence of breast cancer and associated prognostic features in women 75 years of older you know the task force says there's insufficient evidence to recommend for or against screening in this age cohort so we wanted to provide some evidence based on our real clinical experience you know in comparison with the seer data based that was used in the internal medicine article shown here so from 2007 through 2013 at Cornell 68,694 screening mammography examinations were performed and of these screening exams 4,424 were performed in patients 75 years or older on the basis of these exams 5 C's of cancer is found this corresponded to a breast cancer detection rate of 5.9 per 1,000 screening exams which again is compatible with performance benchmarks for screening and approximately 85% of these screen detected cancers in women in this over 75 cohort were invasive so again clinically significant disease you know as an epilogue several years after this 2012 infamous New England Journal medicine article was published by Byron Welsh Welsh actually had to resign from Dartmouth amidst a plagiarism scandal and yet the New England Journal of Medicine still refused to retract his article you know I think as a side note this both thanks the question how does this happen at the level of our nation's highest level of medical journals such as the New England Journal of Medicine and I definitely as energy for clinical imaging interested in this this topic a whole other conversation but I'm definitely as interested as we think about how articles become published in peer-reviewed journals and you know the highest level then go on to impact not only medical but also life perception you know despite this well Welsh is still added in terms of attacking screening homography with this article that appeared just in September 2023 which among other things so he's talking about the new this is the 2023 task force recommendations moving biennial screening from 50 to 74 to 40 to 74 again making wearing my editor's hat there are no references for many claims in those articles I assume this is to satisfy the five reference limit of the the perspective column you know I but it leaves definitely is be wondering how it passed peer review if claim after claim is unsupported or if there was any peer review the article the perspective piece decries the models but says I'm also but then also uses them repeatedly to make the points so this is some of the many problems here but I digress anyway as a final note about the risk of radiation induced fatal cancer from annual screening homography from ages 40 to 80 it's estimated to be a max of 25 per 100,000 women or 0.0025 and a risk this risk is obviously far smaller than the current NIH estimate of lifetime risk of developing breast cancer for women for American women specifically according to the NIH based on current incident rates 12.4% of women born in the US will develop breast cancer at some time during their lives this estimate means that if current incidence rates stay the same a woman born today has about a one in eight chance of being dying to us with breast cancer at some time during her life which percentage wise corresponds with a 12 to 13% lifetime risk of developing breast cancer and this means that higher than average risk is anyone with a greater than 12 to 13% lifetime risk of developing breast cancer and specifically as we know the ACR defines high risk as 20% or greater lifetime risk of developing breast cancer so you know what are the latest ACR SBI recommendations for women in this cohort it's good we're talking about this now because this is a relatively due since last women's history month this is May 5th 2023 JC article with table one listing main actionable genetic mutations associated with an increased risk of breast cancer in alphabetical order from ATM to BRCA to TP 53 and table two from this article takes specific populations at risk and compares the prior with the current 2023 ACR SBI recommendations and the three main changes I'd like to highlight are number one that genetic mutation carriers and their untested first-degree relatives can wait till 40 to start annual screening mammography if they start annual screening MRI at age 25 to 30 and I'm definitely seeing more and more of this with the increased number of high risk screening MRIs I'm reading where there may be a genetic mutation carrier in her late 30s say with multiple prior MRIs but no mammogram you know be curious to know if that's what others are seeing political practice number two for women with dense breast tissue the current recommendation is for annual MRI or as an alternative contrast enhanced mammography or ultrasound and I'm going to come back to this because in a few slides because this is a big statement for MRI and number three all women should have a risk assessment at 25 instead of 30 which really makes sense since some women need to start imaging screening at 25 to 30 so they should know this by 25 if they're going to start on time you know what we hear from many of our patients of course is that they don't have any known risk factor so why should be the why should they take on any of the previously aforementioned risks to which it can be helpful to recall and remind that while some risk factors are modifiable and others cannot some cannot be changed the fact of the matter is that 60 to 70 percent of patients with breast cancer have no connection to these risk factors at all so even if they don't have any risk factors they should still be screened and finally circling back to number two here that for women with dense breast tissue the current recommendation now includes for annual MRI you know the question we wanted to throw out there for further research or further thought after this new lecture is and I don't know the answer but is this reasonable or feasible recommendation when 45 percent nearly half of U.S. women over the age of 40 have dense breasts on the wonder on the one hand maybe yes this is a you know a scientifically valid recommendation to optimize early detection because we do know that MRI is the most sensitive on the other hand how many women would this actually be or ask another way from our perspective as breast damages how many MRIs would this be for us to read so did this answer this question of how many women are in the U.S. ages 40 to 80 in fact so I looked at census data from 2021 and if I add up you know all the the women 40 to 44 45 to 49 50 to 54 etc I take my word with the math this is 65 million women in the U.S. ages 40 to 80 and if 45 percent have dense breasts this corresponds with 29 million women with dense breasts or 29 million MRIs annually yikes so my next question is how many breast damages are there in the United States allowing for the fact that obviously we're not evenly distributed across all 50 states and not all breast damages read MRI and the best estimate I could find was from this 2005 AJA article a portrait of breast imaging specialists which states that the highest estimate of number of breast imaging specialists at the time approximately 2800 that was the number so that's 2025 nearly two decades ago fast forward now to 2024 even if this is rounded up to 3000 and double that's still that's 6000 you know these are my back of the envelope um um calculations that would still mean 29 million MRIs divided by 6000 breast imagers um this would be 4833 MRIs per breast imager per year so that sounds like an awful lot to me I don't know about you um and you know just taking a full view at the look of um breast density issues um and associate insurance you know this is not a political map for the 2024 upcoming election but rather a map which demonstrates that as of this year 38 states and the District of Columbia have some form of breast density notification legislation has a mammogram although not all laws require that a patient be informed about her own breast density some laws only require general notification about breast density and some state laws are more similar than others but there's no state to state standard from state to state on what patients exactly are told or how they will be performed and furthermore it's not like all 38 of these states have associated appropriate um insurance you know even if there is a state insurance law are all women covered for supplemental screening for dense breast and the answer is resoundingly no a state insurance law does not necessarily apply to all policies within the state um for instance self-funded plans out of state plans and national insurance plans may be exempt from state laws and then what about all the women without insurance so you know we're searching circles as best to the beginning you know um looking forward to women's history month again starting just to remind us and that you know we still really need continued research to improve women's health health outcomes access to health care including for breast cancer so that more women's lives can be saved and more women can make history in the future and with that having considered everything on the stated agenda i'll conclude and i'll be happy to take questions thank you for your attention thank you so much for sharing your lecture today at this time we will open the floor for any questions from our audience and you can submit those through a that q and a feature at the bot at the in the zoom box um Dr Arlio if you're able to open up that q and a feature if not it's okay i can read any that come in please please do i don't know what about that it's not a problem um no question yet but you did get a compliment if you want me to read that out loud uh thank you for all the time and effort in this that this must have required the information you provided will be very valuable in advising patients and informing fellow clinicians going forward but i'm glad if it reached you know one person and their patients and providers then it's a worthwhile hour i guess i actually have a question uh that that sort of reminds me is if we have people in our lives who it's time for them to to get screenings and they're adverse to doing so do you have any tips to help convince those folks to do this or it's such a it's such a good question you know i started studying screening mammography uh when i was a fellow back in 2009 and i was in my early 30s and i thought oh this is great you know like i'll study the literature do some research and by the time i hit 40 you know this will will this all be figured out there'll be no more controversy well i'm in the second half of my 40s now and obviously this still is going on but what i'd like to say um to women in my cohort or friends and family are um well depending on the on the person what i think they will respond best to there's actually a study out of nyu in new york city the first um author is jean lee and she looked at approximately 500 breastimeters across the united states um the vast majority of which you know happened to be women and the question was you know if you recommend to your patients and the acr sbi recommendation of annual screening mammography starting at 40 do yourself practice the same thing and 98 percent of breast imagers not only recommend to this but also personally practice that and i said and i i would be one of them i wouldn't miss a single year um for both you know the professionally here you know here's all the professional data but um and also personally as as a woman i wouldn't miss a year and so i recommend the same thing for um my friends and family and you know that personal connection and personal recommendation knowing that you have all the data in the world like how are you sort sifting through it and come what are you doing for yourself i think you know that can be impactful yeah i love that excellent okay so we have a couple questions uh in in clinical nature here so where are we in using ai generated density estimation in practice um such a good question um you know i think it's variable across states and institutions for sure i think the important point is um why this question is so important is like how you know what's the downstream ramifications of using you know ai quantitative based um density measurements will it more objectively and consistently one hopes um define what is dense versus not dense and then be better able to you know define the the the quantity of this cohort and then think more realistically about what's feasible um for you know fair access to women in this dense cohort Gotcha and how about new abbreviated rapid breast MR protocols is that going to change the equation for MRI utilization i i i think so i hope so for sure i mean just anecdotally in my institution at Cornell i feel like from month to month thing week to week i'm seeing more and more um higher screening MRI and as we have more we're only doing them in a certain cohort like in patients with a prior full negative MRI but as we have more those and more of those patients in our past and we get to the present we're doing more and more abbreviated MRI and it's faster to obtain it's faster to read and i still rarely come across a study where i'm like oh i wish i had the full protocol so if it's um if the technical fee of time and the professional fee of interpretation are both shorter then it's going to you know going back to the economics of this and um i used to feel like i have to apologize to talk about economics and health care and that's just the reality in which we practice um then it's going to cost uh cost less and if it costs less then hopefully it will be available and accessible to more women yeah for sure have you heard about any bills that may be moving through states regarding screening now that the usps tf rex were out last summer can you repeat the question again it's i it's a good one it's a complex one yep sure sure have you heard about any bills that might be moving through states regarding screening now that the usps tf recommendations were out last summer yeah um i don't know uh and you can't quote anything specifically um but i will say that there certainly are like um you know private insurance laws that may then um or have in the past um contradict what um you know Medicare has to cover um and depending on the state level one may override the other and also whereas i mentioned there are 38 um states in the country with state level breast density notification laws there also has been a bill at time at the federal level about breast density notification so i think if that were to pass at the federal level how a bill a federal bill about breast density notification interacts with you know the task um force recommendations given that we saw that all comes down from um the federal level congress the senate etc i think will be very interesting to see you would hope that there would be um consistency across recommendations and insurance coverage for access yes for sure fingers crossed yes did you did did you experience an increase in patient callbacks when you were making the transition from film screen mammography to digital mammography um a very good question um i feel like i'm just at the what one that was sort of like over 10 years ago and i was sort of at the cusp of the transition so i can't answer that specifically based on data i know that the FDA approved you know tomo in 2011 slash 12 and i'll say that in in adopting tomo so which is sort of like first we adopt went from film to digital and then the next big step maybe like a decade later was from digital to using tomo i definitely think there was you know a learning curve in that first year or so as with tomo we saw more and didn't have the previous tomo uh to compare it to um and yet ultimately over the longer term now it's been over a decade since um the FDA approved tomo synthesis you know the clearly the literature has shown that 3d tomo synthesis mammography not only decreases the recall rate circling back to the specific question but also importantly increases the cancer detection rate so i would hypothesize that during the transition from film to digital there may have been you know a transitional period in in which there were increased callbacks but that ultimately the benefits of digital um have certainly outweighed that for many reasons including um the the ability to have prior screenings because it's all digitally logged and studies have shown is a great study out of ucs ucsf by um first author jethica hayward who was a um Cornell trained at Cornell as well and she taught she in this study they talk about um that if there are two or more priors screening mammograms on file um the rate of recall you know significantly decreases so i would say just from the aspect of digital cataloging that would be you know having digital over film could potentially decrease recall rates at raw right thank you all right we've got two more for you what do you recommend for women with dense breasts who are underserved by mammography i'm not sure what sense underserved is um meant um i i'm just very transparent with you know women if they come back to my office i and i will show them their mammogram but i'll just you know i'll explain like do you want to see your mammogram yes okay well your mammogram is an x-ray and breasts um you know it's an x-ray and we all have you know fat which looks black black and the fibro glandular prank for the breast tissue looks white and a mass or a tumor could also look white so you can see here like if it's a complete white out extremely dense breasts like it could be hard uh like it could be a limited test and that we might not see something growing in there because it would be totally obscured most people totally get that idea so i said i will say you know to supplement this um for women of average risk we can perform supplemental screening with ultrasound the benefits of which there are you know no additional radiation now of course there's some insurance issues which complicate this um but i will i will say to them like i can't speak to all the you know insurance and financial concerns i completely understate understand these are valid concerns and we have to answer them however for my perspective as a physician i just want to you know show to you the scientific evidence and the rationale behind you know what a test can and can't do so that you the consumer understands the benefits but also the limitations um and i'll say like and for myself personally i do go ahead and get supplemental screening because i also have to dense breasts i don't see that with everyone but i feel like if that personal um discussion is going to take it to another level and put that over their edge and put a patient over the edge and it's going to be beneficial for the healthcare like i don't i i just go ahead and help them because that's what my goal is as a physician yeah that's great okay one more question uh can you recommend articles or books for by rads breast density estimation i have been researching on it with no yield on step by step instructions um good question uh not off the top of my head but circling back to one of the early questions about like the use of a i um and dense uh breast density estimations you know if i were to try to go answer this question as i get off this talk i would go to you know pub med um and look for review articles in the past five years on this topic and see what came up and then you know look at the at the sources and go with a you know high impact journal and i think that would be a good place to start awesome well thank you we got through them all and thank you so much for your lecture again that was excellent we appreciate you being here thank you for the opportunity to speak and um happy leap year today and happy women's history month starting tomorrow absolutely yes and thanks everyone else for participating in this new conference and for for all your great questions you will uh you can access the recording of today's conference and all our previous new conferences by creating a free mr online account we'll also email out the replay later today and be sure to join us next week on thursday march 7th at 12 p.m eastern where dr mark gosselin will deliver a lecture entitled pulmonary thromboembolic disease challenging the conventional wisdoms and algorithms you can register for it at mr online dot com follow us on social media for updates on future new conferences thanks again and have a great day