 I'm happy to be here today during this women's wellness webinar to talk to you today about mammography, early detection, and diagnosis, and women's health. Breast cancer, as you know, is one of the most common cancers in the United States. It's a disease in which the normal breast cells begin to change and grow without control and no longer die. In situ cancer is one of the more common ones in early forms of breast cancer that we see, and it's confined to the breast ducts, whereas invasive cancer is cancer that has spread beyond the breast ducts. Mammography is the gold standard for screening for breast cancer. What is a mammogram? It's an x-ray that is used to check the breasts for breast cancer and other abnormalities. It is the only test that has been shown to reduce breast cancer deaths. Since 1990, the death rate has declined by almost 40%. Mammography can detect breast cancer even before a breast cancer is palpable. This decreases mortality and gives better outcomes and less invasive treatments for patients with breast cancer. Early diagnosis, as you know, is the best chance for successful treatment in any disease, and mammography plays the primary role for early diagnosis in breast cancer. You may have heard about ultrasound, breast biopsy, and MRI. They are complementary to mammography. Also, the clinical breast exam by your physician and self-breast examination are very important roles in screening. The American College of Radiology and the Society for Breast Imaging recommend that the average risk woman starts screening at the age of 40. One sixth of breast cancers occur in women aged 40 to 49. Whereas three quarters of the women diagnosed with breast cancer have no family history of the disease and are not considered at high risk. Higher risk women may need early screening at the age of 25 or 30. When should we stop screening? Well, is it 75 years old or is it older? I'll get back to that later on in this presentation. The reason we start screening at the age of 40 for women with no risk is because of this graph which demonstrates that women starting at the age of 40 start to see an increase in the rate of cancer detection. Whereas below 40 women generally do not have that much of a risk of having breast cancer. Another way of looking at it is at 30 and 20 years of age you have either a 1 in 1,500 chance or 1 in 200 chance of having breast cancer. And those chances increase as you get older than 40 to have a lifetime risk of 1 in 8. Unfortunately, those are the statistics. If you look at the bright side, that means 7 out of 8 of you will never have breast cancer. And I hope that's all of you out there. When we talk about ethnicity and breast cancer, we look at white non-Hispanic women having the highest incidents followed closely by women of color, non-Hispanic black women, and then Native American and Asian-specific women. And then lastly, the least incidence but still high enough is the Hispanic population. When you combine incidents with mortality, unfortunately the mortality rate for women who are black is higher. And that's probably because they're not screened and there has been a great outreach to try to make sure that they get their breast cancers caught early. So I encourage everybody to get screening mammograms. Now let's go into what it is and I'm sure many of you have experienced what a mammogram is. It's usually two views of each breast in compression. I know that this is a painful procedure, but I also am confident because of the technologists I work with who have had experience as many years as I have, which is over 30 years of doing this procedure, they will get you through this exam as quickly and as painlessly as possible. And the pain is definitely worth the whole experience, which is to detect a breast cancer early. The two views that we routinely view of each breast is the cranial caudal or up and down view, and the medial lateral oblique view where the breast is pulled away from the chest wall and angled in a manner that allows us to see as much breast tissue or parenchyma as possible. If the technologist after doing those two views decides that they haven't seen enough of the breast, they will add additional views as we see here. And here are perfect images that we tend to get every day here at Old Bridge or at Raritan Bay Medical Center from our team of technologists of the breast. This is the up and down view, and this is the cranial or the medial lateral oblique view, which allows us to see all the breast tissue or parenchyma and the normal fat that we see within the breast behind it. Here is a screening mammogram that needs to be called back. That type of experience I know is very stressful for all patients. When you get that letter in the mail after you've had your screening mammogram and instead of it saying, normal, we'll see you in a year, it says, please come back for extra views. I know that this is very stressful. And in this particular case, there is a small density here that we needed to get more information on. And so we bring the patient back and we do extra views to bring out that density that we're seeing and sometimes do an ultrasound to see what that might be. I have to tell you that I just finished seeing a patient who we called back for an extra density. And I get no more pleasure than being able to allay their fears after doing extra views and knowing that that density went away and it meant nothing as opposed to what we just saw there. And that's almost more than half the time that you have a screening mammogram that you get called back for. It's just that we want to make sure there's nothing there. And in most cases, that's the case. So let's talk about what this callback or diagnostic mammogram is done for. First of all, screening mammograms are done for patients with no symptoms or no new symptoms. Diagnostic mammograms are targeted studies for the evaluation of a specific problem. That problem may be something that you as a patient experiences. It could be a palpable lump. It could be pain or it could be nipple discharge. If you have any of these symptoms, it's very important that you tell your doctor. And if you haven't told your doctor, tell the mammotechnologist or then we can tailor the examination based on what your symptoms are. An additional reason for having a diagnostic mammogram is that we may have seen the abnormality like we saw on that last patient and we want to do extra studies for that. Also, we could be following up something that we think is going to be benign and we do that more closely every six months for patients who have an abnormality. If you've had a history of breast cancer or recent history of breast cancer, we like to follow those patients every six months for at least two years. Those are the main reasons why we do diagnostic mammography. All mammographies are performed at Rare and Bay Medical Center in Obridge with the state of the art digital 3D mammography system. This is very important and I stress that you find a place to get your mammogram that has this type of technology. Why is that? Well, 3D mammography detects cancers 20 to 65 percent more than 2D mammography. So what this means is that for some women, you'll get a greater number of options for treatment and you'll find your breast cancer earlier. For us as mammographers interpreting the examination, it reduces the time we have to call you back for extra views because the 3D system allows us to see better what is real and what is not. It's as if 2D is looking at the cover of a book whereas 3D is flipping through pages of the book. And here's an example that a logic put out of a 2D image where I defy you to see the abnormality in this breast. But as we slice through the breast, if you will, and look at all the pages, we see more clearly a very concerning abnormality. Well, that was the real patient, but this was one in our practice recently that on the 2D images, there is no way that I can see the abnormality that as we went through the slices, we then pick up this area of concern that allows us to focus with ultrasound on the abnormality that was not palpable with seven millimeters and was a small cancer. Very treatable at that stage. That brings up another topic about breast imaging, which is why we can't see those lesions is because of breast density. It's one of the strongest predictors of the failure of mammography to detect lesions. So with patients with dense breasts, adding ultrasound helps us detect cancers. Cancers also occur five times more frequently in women with extremely dense breasts as opposed to those with fatty breasts or fatty tissue. Mammography detects 98% of cancers in women with fatty breasts and only 48% of women with dense breasts or the densest breasts. If you're interested in more information on this topic, please go to this website. rudense.org. This was so important that 10 years ago, New Jersey created a law to make sure that all imaging of the breasts on mammography had a statement about breast density and the need for perhaps additional imaging to determine if you might be at risk of having breast cancer. Also, many states, including our state of New Jersey, enacted laws to make sure that insurance companies would cover additional imaging for women with dense breasts. And here's the examples of what the breast imaging reporting system asks us to comment on on every patient. It's whether or not the breasts of fatty have scattered fibro glandular densities, heterogeneously dense or extremely dense. And here's a more close-up view of what these four density types are. This is a fatty breast, scattered fibro glandular, heterogeneously dense and extremely dense. 50% of women will have C and D and 50% will have A and D. It doesn't matter your body type. You may have a dense breast no matter what your body type is or a fatty breast no matter what your body type is. Also, I must say that when you see the report and it says that you're dense or you're not dense, understand that we as interpreters have a scale that we have in our own minds and not every interpreter is the same. So sometimes you might have somebody interpret your breasts as being heterogeneously dense and other times they might be scattered fibro glandular breasts. Your primary doctor should assess your risk and based on that may add additional imaging to the mammogram as I discussed MRI or breast ultrasound. Your doctor would discuss the risks and benefits of those additional modalities. If you have no increased risk but have dense perisperincoma, the most important thing is get a 3D mammogram. You might consider MRI or ultrasound because they'll have a higher detection rate of lesions. However, not all of those lesions are going to be cancerous. So some of those lesions will be biopsied and they'll be benign. MRI is better at detecting lesions than ultrasound and you may have to pay out a pocket for that. So if you have average risk, have your mammogram every year. Continue it as long as you're in good health. This is where the age comes into the effector. The age is only a factor if you have other health problems. If your doctor says you're still healthy, get your mammogram. We've had several spry 85-90 year olds come in for their mammogram and that's appropriate. We want to detect an early cancer in those patients as well. Dense or not dense, we recommend if you're at high risk, a screening mammogram for sure and perhaps a screening breast MRI. MRI may be contraindicated in some patients who can't get the contrast for the MRI or are claustrophobic and in those cases, consider screening breast ultrasound. What puts you at high risk? I'm sure all of you have heard that having a relative, a first degree relative especially, a mother, a sister, an aunt, that increases your risk for having breast cancer. If you know that you have a gene mutation such as BRCA1 or BRCA2, that would put you at high risk. If you don't know your genetic test or the results of the genetic test that you have but you have a first degree relative that has a BRCA gene, then you're at high risk. Also, if you've had radiation to the chest for a cancer at an early age between 10 and 30, that will put you at high risk. If you've had a high risk lesion already biopsied in your breast such as atypical ductal hyperplasia or lobular carcinoma in situ, that would put you at high risk. And as I've mentioned dense breasts, I'm a mammogram even put you at high risk. I encourage everybody to get that easy genetic testing. It's a saliva test in most cases and there are foundations that will help pay for that. So to discuss with your doctor when it's best if you're at high risk, you may need screening early on. If your mother had breast cancer at the age of 40, you should start screening at the age of 30. Additionally, you may need an MRI if your breast pragma is dense. Make sure you get examined by your physician and do a self breast exam. Lastly, as far as breast health is concerned, you can follow these guidelines to maintain good breast health and reduce your risk. It's a good lifestyle, exercising 30 minutes every day, eating healthy, maintaining a good body weight, and know your breasts. Self examination every month, you'll be the first one to detect something on an examination if you know your breasts. Stay up with your breast screenings and some doctors recommend vitamin D. This last controversial statement by the American College of Obstetrics and Gynecology was first stated in 2014 and then reaffirmed in 2020. It did not recommend adjunctive tests to screening mammography with women with breasts that were dense, who were asymptomatic. The only reason they felt that it was not recommended is they thought there were too many false positives. I want to thank you for your attention. Please get your mammogram. You can go to these QR codes here and you can make an appointment right now if you'd like.