 Thank you for joining us for our webinar today. I am so excited to be here with you. I wish it was in person, but hopefully next year. But I'm very eager to have this opportunity to introduce myself as medical director of breast imaging at both Riverview and Bayshore Medical Centers, where I hope to build upon what are already exceptional breast imaging programs along with my colleagues, Dr. Wang, Dr. Ko, Dr. Sokolovskaya, and Dr. D'Angelo. So as you all know, it's October. That means fall, Halloween, and of course October is breast cancer awareness month. So what a perfect opportunity for me to be speaking to you today about what has been my personal professional passion for the past two decades, early detection and diagnosis of breast cancer. And I am absolutely certain it doesn't need to be October for us to be aware of breast cancer. I am sure it's impacted all of our lives in one way or another. So during this talk, I'm going to really focus on the W's of breast cancer. Why we screened for breast cancer? Who should be screened? When and how often? What imaging modalities are best? And where is it best to be screened for breast cancer? And then I'm going to offer my own personal approach. I'm an advocate for a personalized approach to screening for breast cancer based on risk, age, and personal goals of breast health. First, the facts. As we probably all know, breast cancer is common. It's really a major health issue worldwide. It is the most common non-skin breast cancer in the world. There are about 2 million cases per year worldwide in the United States, nearly 230 new cases per year. And for those of us so fortunate to live in a beautiful state of New Jersey, there are 8,330 new cases per year. And very unfortunately, breast cancer is a significant cause of death. Nearly 40,000 deaths per year in the United States and 1,250 per year in the state of New Jersey. And this is some data from the American Cancer Society just to show you that if you look at estimates of new cancers in the state of New Jersey, you can see that breast cancer is the number one most common cancer. In fact, it surpasses the other common cancer, prostate cancer, by about 200 cases, and then lung, colorectal cancer, bladder cancer, and melanoma of the skin. However, breast cancer is not the number one cause of cancer related deaths. For that, you can look at this right hand column and see that breast cancer is fourth in line after lung, colorectal, and pancreatic cancers. So where are the hotspots of breast cancer in the United States? You can see it's sort of patchy in the United States. And if you look on the East Coast and try to find the state of New Jersey, you will see that New Jersey is navy blue. It's a hotspot for breast cancer for reasons that I think are uncertain at this time. Certainly on the East Coast, you can see Delaware, Connecticut, and New Hampshire are as well. What about by counties? So here's the state of New Jersey separated by counties. And you can see Hunterdon County is really a hotspot within the state of New Jersey. And where we all are so fortunate to live here in Monmouth County, you can see that breast cancer cases are rather high. There is about 135 to 144 cases per 100,000 women. So breast cancer is common near and dear to us right here in our community and where we live. And breast cancer knows no racial, ethnic, religious, or socioeconomic divides. Breast cancer affects all women. However, there are some differences to be aware of. You can see that white women in the state of New Jersey have the highest incidence or rates of breast cancer followed by black women, then Hispanic women, then Asian and Pacific Islanders. However, the greatest death rate is in black women, which may be multifactorial. We know that black women tend to get more aggressive tumors, triple negative tumors, tend to have a genetic predisposition, and there may be disparities in access to care in terms of screening. But those are the statistics as we know them here and now. The other important thing to know that we talk about breast cancer is one disease, and it is absolutely not. It is very heterogeneous. There are very, very many different types and site types of breast cancer based on whether it starts in the deaths, whether it starts in the lobules. That's the part of the breast, grape-like structures where milk is made when we're breastfeeding, whether it is detected at a time when it's invasive, when it's invaded out of where it started, which it is in about 75% of cases or whether it's in situ, noninvasive, within the duct, contained by the death membrane where it started, different grades based on how aggressive the cells are from grade one, the least aggressive, to grade three, the highest aggressive, whether or not tumors express the estrogen and progesterone receptors or the HER2 oncogene, and all of these differences inform individualized, personalized, and targeted treatment. The good news is out of all the cancers that we may get, breast cancer is highly curable. It's a progressive disease, so early detection is an opportunity to halt that natural progression. If you look at this serodata, you can see that breast cancer is diagnosed within the breast localized about 62% of the time, which happens to correspond with the percent of women in the United States who are screened, so we got to get that number up. The five-year survival is really high, 99%. When breast cancer is detected at a time when it's regional, it's involved the breast and the lymph nodes on the same side, as it is 30% of the time, the five-year survival rate drops down to 86%, and when it's metastatic at diagnosis, as it is unfortunately in 6% of the time, the five-year survival rate goes down to 27%. So why do we screen for breast cancer? I see women very frequently who are a little bit unhappy. They're coming in for a mammogram, their doctor perhaps made them come in or encourage them because they have no family history, so we screen for breast cancer because it is common, and we screen to test a population of healthy women in order to detect unsuspected breast cancer at a smaller size and earlier stage that would otherwise be found perhaps by finding a lump. Why? It increases treatment options and treatments that are minimally impacted to your life and certainly well tolerated. It improves outcome and of course our ultimate goal, long-term survival. Who should be screened? As I said, women need to be screened because the two most important risk factors for breast cancer are having breasts and getting older, and you can see from this curve, which is age and incidence of breast cancer that at about age 30 or certainly by 35, the slope of getting breast cancer, the chances of getting breast cancer goes up in a linear fashion up until the time about the mid or later 70s. So being a woman and getting older, the main risk factor. Certainly some women are at particularly high risk for breast cancer. Women who have been diagnosed are at three to four times higher risk if you have a relative with breast cancer, especially a first-degree relative doubles the risk, greater than one first-degree relative triples the risk, and if you have a male relative with breast cancer, it doubles the risk. A trait that we inherit, dense breast tissue, having fibrous tissue, the composition of our breast is different in all of us, is actually a significant and independent risk factor for breast cancer. Ranges from 1.4 to six times higher risk if you compare women who have extremely dense breast to their girlfriends who have fatty breasts, there's a four to six times elevated risk. If you have a prior biopsy showing atypia, it can increase the risk from four to 10 times. If you've had Hodgkin's disease and received chest radiation at a young age that elevates your risk to four to five times, and the majority of breast cancers, 90 percent are sporadic, but five to 10 percent may be inherited due to a genetic mutation, and that increases the risk from five to six times. There are other risk associations that may be related to our hormonal milieu or ovulatory cycles, so a greater number of ovulatory cycles may cause ourselves to be proliferative, and perhaps DNA mutations occurred during those times we may be vulnerable, so early menses, late menopause, no children can increase the risk for breast cancer. Postmenopausal hormonal therapy with estrogen and progesterone, it's not a direct cause-effect of relationship, but perhaps estrogen and progesterone may promote breast cancers. Postmenopausal obesity is a risk factor and alcohol consumption. There are computer models that can actually quantify the specific lifetime risk for breast cancer for all of us. The Tire Acusic is the one recommended by the American College of Radiology that factors in your breast density, family history, and multiple risk factors. Why is this important? It can inform personalized screening recommendations, and the American College of Radiology recommends that all women by the age of 30 undergo a risk assessment so that if there's possibility of genetic mutation, they can be tested. If it's discovered or they are particularly high-risk, screening can start at this time by the age of 30. So what is the screening test for breast cancer? Well, despite all of the new imaging modalities that you may have heard of, mammograms remain. The primary imaging modality and the modality proven to reduce deaths from breast cancer, they are relatively inexpensive, they are fast to perform, they're safe and well tolerated for the most part. Even if compression is uncomfortable, it's brief. They're readily accessible to large populations of women. We do mammograms starting early in the morning. We go till 7.30 at night and we even do screening mammograms on the weekends. They're accurate and they have been proven to be effective. And as you know, 3D mammograms are actually now considered the gold standard and probably the most impactful new technology I will see in my career is 3D mammography, also known as digital breast tumor synthesis. Why? It is simply a more accurate, better mammogram. Not only does it increase our detection of breast cancer, but it decreases the false positives. And of course, 3D mammograms have been available for a number of years. But if the next generation is out and Bayshore Medical Center has the latest and greatest 3D machine, which is not only higher resolution, but it's more comfortable because there is a curved paddle for compression. How do we know mammograms are a benefit? Well, there have not been one, two, three, but six randomized control trials. These trials are the gold standard for proving effectiveness of a screening test. And these have all shown a reduction in breast cancer deaths by 25 to 52 percent in women invited to be screened compared to those not invited. We know that since screening programs have been developed in the 1990s, breast cancer death rates have decreased by 40 percent. And from my perspective, having been in practice for a couple of decades, early detection due to mammography has really led to a paradigm shift in how we treat breast cancers because the overwhelming majority are early stage lymph node negative tumors. This has led to lumpectomies instead of mastectomies. Sentinel lymph node biopsies, just sampling one or two lymph nodes instead of full axillary lymph node dissections, even radiation therapy and chemotherapy now may be optional depending on the specific stage and specific characteristics of tumors. So it's a whole new frontier in treatment due to early detection. Of course, no test is perfect. And there are limitations to screening that everyone should be aware of. Mammograms may miss or not detect about six to 10 percent of breast cancers, even using 3D mammography, especially in women who have dense breast tissue. Mammograms may not detect 20 to 30 percent of breast cancers in those of us who have dense breast and are therefore at higher risk. So it's sort of a double whammy. These interval cancers, interval cancers or cancers that are found by finding a lump instead of being found on a mammogram tend to be aggressive tumors. So we need to find other modalities to add to mammography to find these tumors. There are some harms to screening and those those are called false positives. I call false positives false alarms. Women who get recalled from screening for additional views, it's common. We recall about 10 to 14 percent of women. You should know that if you get the phone call to come back in, chances are everything is going to be okay. The cancers, the PPV1 are cancers divided by women called back are only 6.5 percent. So if you get that phone call, there's a 93.5 percent chance everything will be okay. And even when we recommend a biopsy, 80 percent of the time they're benign. And so we've pushed that threshold for early detection very low. There's lots of things we find on a mammogram, but just because we find something doesn't mean it's cancer. These are called false alarms. And then theoretically there is over treatment. Some cancers we treat may never have caused death. And so generally there's now a de-escalation of treatment. So we tend to treat the woman, her age, and the type of tumor diagnosed. So the current average risk screening recommendations you should know are confusing because those of us physicians that are in different specialties are governing bodies have slightly different recommendations. Because of the attempt to balance the undisputed benefits from screening versus the harms which are these false positives or what I call false alarms. There is a consensus though among all governing bodies and that is annual screening mammograms beginning at the age of 40 undisputedly save the most lives. So that's where I put my focus on. The recommendations from the NCCN, that's the National Comprehensive Cancer Network, the American College of Radiology, Society of Breast Imaging, and Medical College of Gynecologist is annual mammograms starting at the age of 40 in every year. And continuing till a life expectancy of at least 10 years. So mammograms are for healthy vibrant women who expect to live another 10 years at least. If you have a first degree relative who had premenopausal breast cancer, you want to start screening 10 years earlier at the age in which your relative was diagnosed. And also some women would need to consider supplemental screening with MRI as well. And are mammograms enough? Well, as you're very well aware, when you get your letter about your mammogram, you're informed what your breast composition or density is. And that is because we want to inform women who have dense breasts that that may limit how well mammograms detect breast cancer. And it also elevates the risk of breast cancer. And so that's led to an interest and a demand for what we call supplemental screening, not instead of a mammogram, but in addition to a mammogram. And just to show you what different typical breast compositions are like, I always tell women, mammograms are sort of like thumb prints. No one has the exact same pattern as any other woman. In fact, I recognize some of my patients through their mammograms. And the composition of the tissue under the skin really ranges from mostly fat, as you can see in this case, the tissue is mostly dark. Fatty tissues have a darker appearance compared to average a mixture of fat and wispy fibro glandular tissue to what we call heterogeneously dense, whiter areas within the tissue. And then category T by Reds D is extremely dense. The tissue is predominantly fibrous. And so the risk is greater in these two categories, C and D, women who have heterogeneously dense breasts and extremely dense breasts. So this leads me to my personalized approach to breast cancer screening. I'd love to reach the point where we can have the access to risk models so that we report the lifetime breast cancer risk in all women who come in for their mammogram. After all, we are asking you and you are informing us about your age, your family history, your hormone use, and we can calculate your risk, which then informs screening recommendations, we can therefore identify women who have a lifetime risk of greater than 20%. That puts you in the high risk category. We can know whether you should be referred to see that there might be a genetic mutation for genetic counseling. And certainly, if you have a history of breast cancer, we can identify women who are in immediate risk and have dense breasts, they may be candidates for ultrasound. And of course, all of this informs what I call modality specific screening recommendations, which always starts with a mammogram, which should be 3D in all women, but may include other imaging modalities such as breast ultrasound and breast MRI and emerging modalities that you're going to hear about in the future include abbreviated MR, which is a shortened version of an MRI for screening purposes and contrast enhanced mammography. And I'm just going to touch upon these modalities briefly. I'm sure everyone's heard of breast ultrasound, it has so many medical uses, it's used during pregnancy. And it's also invaluable for breast imaging. It's very well tolerated. It's fast to perform. It's completely safe. As you know, it uses sound waves. It's cross sectional imaging. So unlike a mammogram, there's no overlapping tissue. It's not impeded by breast density. And we, and it does increase what we call the breast cancer detection yield. When you do supplemental screening in with ultrasound and women who had dense breasts, we can find additional breast cancers. Generally speaking, it's about three to five per thousand women that are screened with ultrasound. And we do do supplemental screening with ultrasound in women who have dense breasts, who may be at intermediate risk or elevated risk for breast cancer. You should know if you're going to have a breast ultrasound for screening purposes, you want to go to a center that's highly specialized and dedicated and does it all the time because quality of the exam depends on the equipment and the expertise of the people and dedication of the people doing the exam. And I'll just show you an example of a mammogram. This is a 57 year old woman with, hopefully I've trained you and you know that this is an extremely dense breast tissue. There was a family history of breast cancer in her sister. This mammogram is negative and ultrasound detected a very small invasive cancer. Can you see these cases? What about contrast enhanced MRI? So MRI of the breast with contrast really combines two unique features in breast imaging. Number one, the soft tissue detail of an MRI is really quite incredible. It's cross-sectional imaging. There's no overlapping tissue, but what is key is giving contrast. When we give contrast through the vein and then image the breast with MRI, we are getting something we don't get with mammograms or ultrasounds. And that is functional information. What areas have an increased blood flow and abnormal blood permeability because very aggressive breast cancers in order to grow, in order for cells to divide, the very first thing they develop the ability to do is bring in abnormal vessels and those vessels are leaky and MRI gives us that unique information. And so we do do MRIs for screening purposes in a certain subsets of women who are at particular elevated risk. If you have a lifetime breast cancer risk of greater than 20%, you meet criteria for having MRIs yearly. If you have a known genetic mutation, the most common are the BRCA1 and BRCA2 or a first-degree untested relative. You meet criteria for breast MRI in addition to mammograms. There are additional no mutations lying specifically if you've got one of those or you're an untested first-degree relative. You meet criteria for an MRI. If there's a history of chest or mantle radiation between the ages of 10 and 30, those are mostly women who have had Hodgkin's disease. If you have a personal history of breast cancer and you have dense breast tissue or you've been diagnosed at the age of 50 or below, we do MRIs in those patients as well. And here's just an example. This is a former patient of mine who has a known BRCA2 mutation. In fact, she's had a breast cancer in her right breast. And you can see how brightly things can show up on MRI using contrast. So this is an area in the breast that is taking up the contrast very brightly. This was also found on ultrasound based on the MRI. And this is an invasive ductal cancer. I'm very interested in an emerging imaging modality called contrast-enhanced mammography, which combines the incredibly high resolution of our 3D mammogram's digital breast homosynthesis with contrast, which I've already told you is key to detecting particularly aggressive tumors. And here's a diagram. When cells are actively dividing, they have the ability to bring in abnormal vessels. And so contrast-enhanced mammography is like an MRI, but using a mammogram. So instead of a 35 or 40-minute exam where you're laying prone and you go into the bore of the magnet, this is just like having a mammogram after contrast. So it's about a five to 10-minute exam and you get that key information that you get with contrast. And here's just an example of a contrast-enhanced mammogram. We do two exposures, one at a low KV, one at a high KV after contrast is given. We do a subtraction image. And just like that MRI I showed you, you can see rightly enhancing abnormalities of the breast, even in breast as extremely dense disease where this tumor is not seen. It's hidden by that dense breast tissue. So that's an emerging modality that I'd like to certainly implement sooner in the next coming years at both Bayshore and Riverview Medical Centers. So in conclusion and toward the end, where should women have mammogram? Well, women should have a mammogram at an ACR accredited breast imaging center of excellence. Why? In order to do mammography, all centers need to have an accreditation in mammography only. But in order to be accredited as a breast imaging center of excellence, you have to be accredited by the American College of Radiology in not only mammography, but breast ultrasound, breast MRI, and tomosynthesis or stereotactic biopsies. And that assures safety. That assures that you are receiving your care at a center that has dedicated staff, dedicated personnel, physicians who are highly trained and have very high level of expertise in breast imaging. That way you have access to multimodality screening, minimally invasive breast biopsies with, most importantly, a continuity of care. And also access to a multidisciplinary team of specialists, surgeons, oncologists, radiation oncologists, genetic counselors, nutritionists, nurse navigators, and breast tumor boards. And just to introduce you to our team at Bayshore and Riverview Medical Centers, in addition to myself, we have Drs. Juan, Dr. D'Angelo, Dr. Ko, and Dr. Sokolovskaya. They all have a very high level of expertise in breast imaging. They are wonderful, awesome, compassionate physicians, each and every one. And I'm very proud to work with all of them. And I'm very proud that both centers are breast imaging centers of excellence and have recently both centers have just passed both their ACR accreditation and MQSA inspections. So with that, I think I will open this up to any questions you have because I've talked for quite some time. So I think, Kalen, I'll be able to see questions. I think, yeah. Perfect. So I'm not sure if I could hear people ask questions or whether I should just answer questions that people have typed in. I think you can just read out the question and then answer that way. Okay. Now, full disclosure, I'm relatively new. I started at Hackensack Meridian Health in June of this year. So the first question is 3D mammography always performed at JFK. So I really do not know. Kalen may know. I can tell you that 3D mammograms are not performed everywhere in the country, but certainly will be quite soon. It's reached the point where they are now considered the standard of care. And certainly since I've been in practice, when I had been consulted to do second opinions regarding cases from the outside, and I believe including JFK, they have all been 3D mammograms. Kalen, do you have any additional information? I actually do not. I'm only at the Short and River View, so I can't answer that question, but we'll make sure to get that answered for you. I'll send you a separate email. Right. I have visited several sites at Hackensack Meridian Health. They have all been 3D. So I'm going to assume, but I don't know for sure that JFK is as well. And then another question somebody had was, can topical estrogen cause breast cancer? So first of all, I'm going to start the answer to that question that estrogen and progesterone are estrogen alone. It's not a causal effect relationship. For example, we know that cigarette smoking causes lung cancer. That is a direct cause and effect. Astrogen and effect progesterone may actually promote certain breast cancers to find a happy environment to grow, to divide, to do their thing ultimately to a metastasis, because it's a promoter more than anything else. Topical astrogens that are used, there is some absorption. Whether or not they promote breast cancer is not completely known, because the studies were done with hormonal therapy, which is generally pills. If you use topical estrogen, by that I mean maintenance on the skin for hormonal therapy, then you're definitely getting absorption and there could be a promoter effect for breast cancer. If you use estrogen, vaginal suppositories, post-metaposly, then the absorption is really minimal and it's probably safe to continue using them.