 Okay, hello. Hi. My name is Dr. Melanti Klu. I'm the chief of breast imaging here at Edison Radiology Group. I've been here a long time, over 20 years. And I think our breast center here at JFK is like a little family here. And I think we provide great service. But thank you for inviting me today for the Women's Wellness Lunch Series. It's a great honor. And we'll discuss, especially this month is October. So it's breast cancer awareness month. So I think it's important that people understand and are more aware of getting their annual screening mammograms. And today's talk is basically like where you get your mammogram matters, which is very important. So we'll just go over just some breast cancer statistics in 2022. So breast cancer, it's the most common cancer diagnosed in women. So 12.8% of the women will be diagnosed with breast cancer during their lifetime. There are like more than 287,000 cases anticipated for this year. And the estimated breast cancer deaths in 2022 is estimated to be 43,250 in this country alone. So I'll just give you just a little introduction to our breast center here at HMH JFK, here at 60 James Street in Edison, New Jersey. We're a separate imaging center building across the street from the hospital, which makes it really convenient because it's kind of like one-spot shopping. So it's convenient in that it's across the street from the hospital. So it's separate from the hospital. So you don't have to deal with the hospital, a little bit of the busyness and the confusion sometimes on the parking, where it's really easy here. So when you're coming down James Street and at the traffic light, instead of going to the hospital direction, it's on 60 James, which is across the street. It has its own parking facility, which makes it like super easy. And all the patients really love that it's like an easy in and out instead of trying to maneuver and trying to find yourself somewhere in the hospital. So all the imaging is done. And here at the 60 James Street, because we have our breast center here and also the MRI building is here and kind of like all the modalities for breast imaging with mammography, ultrasound, stereotactic core biopsies and MRI and bone density are all located here in this separate facility, just a really easy access across the street from the hospital. So this is just the entrance. So when you come through the entrance, they pretty much have like a pretty light filled mean registration room and waiting room. So this is kind of like the general area where all the patients come in once they enter here at 60 James Street, where the MRI is on the right side of the building and then the breast center is located on the left at the registration desk. So when we make a left, we're going to be entering into the breast center. So entering into the breast center, it has its own separate waiting room for women, pretty much mostly only. And here it's pretty spacious, kind of like to spread the patients apart. But this is kind of where the first area where the patients come and enter, and then they come to after registration, and then they wait here to get their mammogram and the technologist comes pick them up here in the breast center waiting room. So we have three 3D mammography units here at JFK. We're fortunate to have two of them have upright stereotactic biopsy capability. So this is a picture of Adriana. She's one of our senior technologists. She's amazing. She does, she's just showing us one of the units here. And then that pink pad you'll see there, it's right on top of the mammal plate. So when a patient comes in and they get their mammogram done, we offer this mammal pad, which is a great convenience and really lucky to have for the patients instead of feeling like a cold plate there. They're able to be able to give a mammal pad for every patient. And then this is just a typical mammography unit that does 3D. So what is a mammal pad? It's a breast cushion and it's designed for women and it was designed by a female breast surgeon. It's FDA cleared. It does not impair image quality. So the images are great even without the mammal pad. And it just helps the patients relax during their mammogram so they don't feel it's like an extra cushion when you have your mammogram. We're fortunate in that we're able to provide this mammal pad for every patient that comes to JFK. So again, there's no cold hard plate against the breast. It just gives an extra comfort for the patient. So they are more relaxed than probably be able to give a better picture for their mammogram because they're more relaxed and not feeling that cold hard plate. So again, it's warm and it makes the mammography a little bit more comfortable experience than without the mammal pad. And we're able to have really great images because the patient is more relaxed and it's not as uncomfortable as without the mammal pad. So this is just a video of Adriana. She's just showing what we do for every patient. They put a new mammal pad before each mammogram. So this is just again the mammography machine showing that the mammal pad is placed there for the patient before their mammography is done. So we do 3D tomosynthesis for every patient, which is like amazing. So this video just shows how we have one millimeter slices on how tomosynthesis is performed. And then all the images are kind of compiled together. So it's kind of like pages in a book. And we scan through the breast looking through the depth of the tissue for any lesions, architectural distortion or masses or speculation, which are like signs of breast cancer. So why should we start screening at 40 years old? So breast cancer is a problem for women in their 40s. One in six breast cancers are found in women in ages 40 to 49. The 10 year risk for being diagnosed with breast cancer in a 40 year old woman is one in 69. More than 70% of women dying from breast cancer in their 40s belong to the 20% not being screened. So the biggest risk factor for any woman is age. As we age, our breast cancer risk increases. So as we get older, we have more risk for developing breast cancer. So this is an image and it shows how mammography has markedly improved over the many decades. The first image on the left is really a poor quality mammogram that was done like decades ago, where we barely can see the skin, we can barely see, we just see the very white dense breast tissue, but nothing much underneath it. Subsequently, after that, the blue image is what we call zero mammography, which doesn't happen. We don't do anymore, but it was just somewhat maybe of a slight improvement over that first initial left image. And then over the last 20 years, the third image got a little better where we're seeing a little bit underneath the breast tissue more. And then this last image on the right is kind of what our high quality mammogram shows now, where we actually see the skin, we see nipple detail, we see the dense tissue with the stromal layers. So it's a marked improvement over the last decade that mammography has markedly improved and helps us catch, especially small breast cancers that are hiding underneath that dense breast tissue. So this is just a chart. It just shows how women in the ages from 40 to 84, from 1969 to 2015, is the age-adjusted US breast cancer mortality rate. It just shows that how the graph from 1969 to 1989, where mammography screening really took off, and then many patients started doing their annual screening and how the mortality decreased 42% from the year 1989 to 2019 now, and that there are 384,000 to 614,000 live states. So yes, the mammography has reduced breast cancer deaths. So the benefits of screening is that there's a 40% drop in breast cancer deaths if you do your annual screening. There is less extensive surgery for screening-detected cancers if you do your annual mammography screening. There's less chemotherapy for screening-detected cancers because you're finding the cancers that are smaller by doing annual screening in general. So mammographic screening is able to detect a large amount of breast cancers before they can be felt, and when they are at a smaller size and earlier stage and more likely to be curable, which is the goal of screening mammography. And again, the chemotherapy is much more effective for screening-detected breast cancers. So beginning screening mammography at the age of 40 years old does save the most lives. So starting your yearly mammogram at age 40 has cut the breast cancer deaths by 40%. Yearly screening starting at age 40 versus every other year between the ages of 50 to 74 saves approximately 13,770 more lives each year. So the goal of screening is to find the cancer as early as possible to save as many lives as possible. So this is just an image. When you get your mammogram reports, it'll tell you about your different breast densities. So this is just the picture showing the variation of the four categories of breast density that women categorize as. So the first left image is a fatty breast, and you can see how it's more darker. And if there are lesions there, usually breast cancers show up as white mass on the mammogram. It's more easily seen on mammography, where the second image is what we call scattered fibro glandular densities. And you see a little bit more of that white stromal tissue. And then the third image is what we call heterogeneously dense breast bronchoma. So it makes it a little bit more challenging to find the lesions underneath that white denser tissue. And then the last image there is more of a white mammogram, where this is what we call extremely dense breast bronchoma. And sometimes underneath this dense tissue, it makes it sometimes a little harder to find lesions. But thank goodness with 3D mammography, we're able to page through the breast and still see it better than without the 3D. So this is just the picture showing the four different variation of breast density that women have. So you're basically most people are born with whatever density they are. Most people over time might have dense breasts and then develop fatty or breast, especially after having kids. Your breasts become fatty or some people actually there's a small percentage of the population that always have extremely dense breast bronchoma, like that image on the right. And even no matter what throughout their lifetime, they have very dense breasts. So one of the adjunct tests that we do here at the breast center is, this is a typical breast ultrasound room. So we do the screening mammography and then some patients, especially with the dense breast, they have like a breast ultrasound done to look under the dense tissue. So here is just Jody, one of our ultrasound technologists and so one of our machines, we actually are fortunate to have three breast ultrasound machines here at the breast center. And then this is just the stretcher bed with the sheet on where the patient would lie on. And then our technologists would do the ultrasound with the patient lying on the stretcher bed there. So risk of mammography. Some of the risk of mammography is that some patients get recalled and then some eventually might go to biopsy. So when we have do screening mammography, usually one out of out of the every 100 women who will get a screening mammogram, 90 of them will be told that their mammogram will be normal. There will be a small percentage of patients, approximately 10 to 12% per year where they need to are recalled and they need to come back for additional imaging, which is like spot compression views or magnification views, or they might need a breast ultrasound in order to evaluate an abnormality. Six will be reassured out of that 100 that their mammograms are normal. Two might be asked to return in six months for a six month follow up exam for something that's probably benign. And two will be recommended to probably might have a needle biopsy. So recall is not that common among the screening mammogram patients, usually it's only like 10 to 12% per year. And biopsy is rare. It's only 1 to 2% of the patients per year. So the harms of screening are negligible compared to dying from breast cancer. So actually, I'm going to go over a few cases. These actually were just over the past week. This helps you see what we look for when you come in for a screening mammogram. These are all abnormal patients. So this image here on the left is a typical what we call like a cranial cauda view. So it's one of the four views that we perform when a patient has a screening mammogram. Here in the back part of the tissue, you see this old void, what we call like a speculated mass where there's like little striations from the mass extending from the posterior tissue. The image to the right is what we call an MLO image, which is the other corresponding view we do for each breast. So typically on a screening mammogram we'll do what we call a cranial cauda view, which is this image on the left and also an MLO view. So we do two views of the breast for screening mammogram. So here the abnormality is there is like approximately a two centimeter mass on the posterior tissue. And then this one actually turned out to be like an invasive ductal cancer. So we characterize the image by bringing the patient to ultrasound. So this is the image of the ultrasound of that same patient where we can see that the mass is solid. The blue and red on the image is what we call color Doppler flow. So we see that there is some flow of that little blue dot on top of the mass there. The mass looks irregular and has posterior acoustical shadowing. So this is very typical of what we call an invasive ductal breast cancer. Okay. And then this is another image of another patient. So this also patient came in this past week. The left image again is we usually like again we get two views. This is the cranial cauda view on the left. The right is the medial lateral blight view. So we always get again the two views of the breast. And in here you'll see that there is an abnormality. We have to do have a brink come back for extra views. So here in the middle of the image this may be a little bit hard to detect but you see all those little white dots in the middle. These are what we call microcalcifications. So these microcalcifications are branching pleomorphic and they kind of extend about two centimeters. So this is the first image on the left is the cranial cauda view. The image on the right is the what we call like a 90 degree lateral medial magnification views. And this just shows those little calcifications. So this is kind of what we look for in mammography to look for signs of breast cancer. And this turn these like little calcifications since they're pleomorphic and branching are very highly suspicious for a breast cancer. So the patient underwent what we call a stereotactic core biopsy. This is our stereotactic prone table here at the breast center. We also have upright capability but this patient had we put her on the prone table. So this table is our biopsy table and usually the patient lies on top of the table and there's a hole in the middle of table and the patient's breast hangs through the hole. So we take an image of the little calcifications that you saw on that last mammogram and then we give a local anesthetic and then put a needle in take a small amount of tissue to get those little white dots of calcifications to send for we did for a biopsy and send it to pathology. So this is an image on the left is the sample we took of those little micro calcifications. This is an X-ray of the specimen that was obtained after the biopsy. So within the specimen there's these tiny little white dots of calcifications. And then we know we had a good sample because we see these little dots of calcifications and then we send this off to pathology to get a diagnosis. After the biopsy we usually put a little micro mark clip in just to show the area that was biopsy and it corresponds to the area on the mammogram. So that's that right image where you see that little it's like a square dot with like a little hook on top. That's the biopsy clip and then the black inside it is the air inside the cavity that was biopsy. So we know we had a good sample from that specimen there on the left and that it corresponds to what we wanted biopsy on the post biopsy mammogram image. And then that that last case turned out to be a breast cancer. So that was being sent to surgery. So this is a third patient that I had this past week. This one is a 90 degree lateral medial view of the right breast. And then this is a typical screening mammogram picture where at the top of the picture it's kind of hard to detect but we're able to see it. There's like small little white dots of calcification. So usually for mammograms to look for signs of breast cancer we're usually looking for these little calcifications or masses or speculation or architectural distortion. So here on this image there's a tiny tiny like two three millimeter cluster of those little calcifications right at the top right edge of the image if you can see it. So we did a corresponding magnification views. So within that circle you see those tiny tiny little white dots of calcifications that made like a small cluster of calcifications. So that was suspicious for us to send for a biopsy. So this one is we did this on the upright machine because it was kind of a far back location. So that little white dots of calcifications on the top part of the image. The long white line is our needle that we usually used for a biopsy. So we see that the needle is directed right to those little white dots of calcifications at the top edge of the image. So the second image shows that we advanced the needle to the area of the calcifications. So just at the tip of the needle there are those little white dots of calcifications that we sampled for biopsy. So we take a specimen image just to make sure that we were able to obtain the calcifications for biopsy. Here on the sample of the specimen we see tiny little white dots of the calcifications. So we were able to successfully biopsy those small calcifications and send it to pathology for further evaluation. This actually turned out to be a small ductal carcinoma in situ which is last age zero small breast cancer that's in the breast. And I think this one is our final case from this past week. So here is our typical mammogram picture where we have two cc views of the breast at the top left part of the image. On the bottom left image is the corresponding medial lateral oblique views. So at the edge of the top of the cc image there's a small little mass that's seen there. So these are what we look for. We're trying to find small masses and calcifications, distortions, speculation in order to find small signs of breast cancer. So there at the top edge of the image we did an ultrasound to find it on ultrasound because it's always easier to do the biopsy under ultrasound instead of mammography if you have a choice just because it's quicker and we can do it real time. Here on the ultrasound we see a small hypo-coic mass. The blue dots on the image here on the right show that there is increased color flow. The edges of the mass are a little bit irregular. So actually this was a really small infiltrating ductal breast cancer that was found just from our screening mammogram. So another test that we do here at the breast center to provide for our patients so it's kind of like one-stop shopping is this is our bone density machine where patients usually get them after 50 years old typically every other year. But the patient usually lies down on this table and then we're able to get bone density images and figure out their bone density calculations from here. So you can redo them. Some patients have their screening mammogram and their bone density done at the same time in order to get both tests done on the same day. So here's my wonderful JFK nurse navigator team. This is Karen and this is Teresa who we love. They're excellent. They're able to provide great service to provide patient continuity of care. So when the patient starts off with the screening mammogram and there's an abnormality found usually my nurse navigator team follows them up. Make sure they're ready for biopsy, follows them up post biopsy. Make sure that patients are coordinated, getting their appropriate care if needed. If everything is benign then we usually just have them come back for a six-month follow-up post biopsy follow-up. But if there are like breast cancer that's found usually our nurse navigator team tracks them make sure they're set up with the appropriate people. If it's a surgeon or oncologist. So my nurse navigator team is invaluable and I'm so glad that they're here with us. And this is Dolores Koch. She's our breast center manager and then she's amazing. Make sure that our breast center is run efficiently and that patients concerns are taken care of and that we're kind of like one family here at the breast center especially I feel connected with all of them because I've been here 20 years and many of them have been there even longer than me over 20 years. So I think we have a great team here at the JFK breast center. So just in summary screening mammography is a proven lifesaver. There's a 40% reduction in breast cancer deaths with regular screening mammograms. And again as I said the most lives are saved with annual screening at the age of 40 years old. So it does matter I think where you get your mammogram. Breast center here is ACR accredited for a breast imaging center of excellence. So it's one thing that you should probably always try to look for in a breast center as especially when you're ACR breast imaging center of excellence you have to go through a lot of qualifications for that has to get renewed every few years to make sure that you're on top of everything. And especially being in a comprehensive breast center we're able to provide all the modalities here at one site where we have 3D mammography for all our patients. Breast ultrasound also even easy access and breast MRI with breast MRI biopsy capability is also here in the same building. And that's just what I said with stereo ultrasound MRI all in one site. And also we have a very dedicated breast center staff and we have board certified physicians on site. One note that some people might not consider is that they get their mammography done at a site but there are no radiologists or physicians supervising the site and the mammogram or images from whatever study are performed are sent to a separate site you know where there is a board certified physician but our staff is and board certified physicians are on site. So where you have your mammogram matters this is our just our breast center which I think it's great. Dolores there on the top Kristi Pomassano she's our biopsy coordinator so when there is an abnormality that is seen and use a biopsy she follows them also throughout the process and again our nurse navigators who are invaluable. So this is just a video it shows Cheryl Crowe when she was diagnosed with breast cancer her experience so I thought it was just interesting this is from Good Morning America when she did this in August of 2020. One second everyone we're just having a little technical difficulty we'll be right right now and we're all living through this uncertain time it's really important for women over the age of 40 to continue to be diligent about getting your mammogram because early detection really does it does matter and we can't take care of our loved ones if we don't take care of our own health. So in 2006 I was diagnosed with stage one breast cancer I went into my routine mammogram which obviously I was dreading like everyone does and I was extremely athletic good eater you know very healthy no family history so I wasn't worried about it and I came out with a stage one diagnosis after having the radiologists say come back in six months we see something suspect. I didn't wait six months because was recommended that I didn't and I think because of that I had a lumpectomy in radiation as opposed to having perhaps a more you know a harsher treatment. I find that every year throughout the years I am talking about early detection because we still don't have a cure for breast cancer and until the time that we do our best weapon is early detection. We were all very recommended at the very beginning of this pandemic to put sort of our less crucial visits to the doctor on hold but it really is important that we continue to observe this annual routine of getting a mammogram after the age of 40 it can really make the difference between having a very mild treatment or having something much more taxing. I think women in general already are very astute at taking care of everyone before we take care of ourselves and that is the lesson in this pandemic as well. We're all making sure that our kids are staying healthy we're all wearing masks we're socially distanced my kids are going back to school I'm following all the regulations and making sure that they know all the guidelines and yet it is still important that come November when I schedule my mammogram that I keep that appointment because life is going on it is continuing to go on breast cancer will continue to exist even during a pandemic. I just wanted to thank everyone for joining today for this webinar hopefully everyone got some insights on how important it is for doing your annual screening mammography because mammography does save lives. Thank you so much. Thank you Dr. Milantic-Lew. I want to thank everyone for joining and just let you know that we will be sending out a recording of this presentation probably within a week or so and if there are any questions please do use the chat not the chat I'm sorry the Q&A bubbles below. I also want to just throw out a question myself as both Shallow Crow and and Dr. Milantic-Lew mentioned that the annual visit is very important I heard a story recently of one of our patients that just for whatever inconvenience or reasons didn't didn't do one annual exam and skip the year and the next year it was found that you did have breast cancer so just want to reiterate that is there anything about that particular situation or to speak about it more Dr. Milantic-Lew? Yes well just in my personal experience because of the pandemic some people have kind of delayed their screening mammography and unfortunately over the last several months you know especially I've been seeing like larger breast cancers than usual so that totally affects people's outcome and treatment that so that's why it's just really important to keep up with your annual mammography every year because if breast cancer is really common and if it hopefully it never develops but in you but if it does you'll find it small and especially now with when they do treatments for chemotherapy or estrogen progesterone positive if you're who to use that is the chemotherapy is much more targeted than it was you know many years ago where they kind of just did blanketed chemotherapy where now finding breast cancers you know really does save lives and it's just really important to do your annual mammography because if it ever develops in in you then hopefully it's just found small and and it's probably curable