0:02

Hello, and welcome to today's noom Conference,

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co-presented by MRI online and A A WR.

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The A A WR was founded in 1981 to provide a forum

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for issues unique to women in radiology, radiation oncology,

0:16

and related professions.

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The association sponsors programs that promote opportunities

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for women and facilitates networking among members

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and other professionals as well.

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A A WR strives to meet the diverse

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and changing needs of its members

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through mentorship opportunities for the next generation

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of women radiologists.

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You can learn more about their mission and membership@a.org.

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We're thrilled to partner with A A WR in these lectures

0:43

as part of our shared commitment to advancing

0:45

and supporting women in radiology

0:47

and transforming the way radiologists learn and thrive.

0:51

Today, we are honored to welcome Dr.

0:53

Elizabeth Kagan Arle for a lecture entitled

0:56

and preparation for Women's History Month screening

0:59

Mammography Saves lives.

1:01

Dr. Ar completed her diagnostic radiology residency

1:04

and breast body fellowship at Weill Cornell Medicine in

1:08

New York City, where she's been on staff since 2010.

1:11

She's currently a professor of radiology there

1:13

and also serves as editor in chief

1:15

of the radiology journal Clinical Imaging.

1:19

At the end of the lecture, please join her in a q

1:21

and a session where she'll address questions you may

1:23

have on today's topic.

1:25

Please remember to use the q

1:26

and a feature to submit your questions so we can get to

1:29

as many as we can before our time is up.

1:31

With that, we're ready to begin today's lecture to Dr. ar.

1:35

Please take it from here.

1:38

Hello. Thank you for that introduction

1:40

and thank you everyone who's joining us for convening

1:43

for this noon conference about, um,

1:45

screening mammography in light

1:47

of upcoming Women's History month, starting tomorrow.

1:50

Um, as mentioned, I'm Elizabeth Arlow, professor

1:53

of radiology at Cornell,

1:55

where I practice breast and body imaging.

1:57

And I am also, um, required to disclose to you

2:00

that I'm editor-in-chief of the radiology Journal Journal

2:03

Clinical imaging, you know,

2:06

OC October in certain cer circles, certainly in radiology

2:09

and, uh, breast imaging.

2:11

And women's health is obviously all well-known to us

2:13

as Breast Cancer Awareness Month.

2:16

Um, and currently, uh,

2:18

for one more extra day on the sleep year.

2:20

We are in February Black History Month.

2:23

And as we look, uh, forward to tomorrow, um, to march, um,

2:27

it will be Women's History Month.

2:29

And to tie, um, this in with today's lecture topic

2:33

of screening mammography, there are actually so many women

2:37

who have made history who have also had breast cancer,

2:41

including those listed here

2:43

and seeing all these known names and faces.

2:46

I think this reminds us, certainly reminds me that

2:48

as we get ready to celebrate Women's History Month,

2:52

to maybe also remember to celebrate screening mammography

2:54

because, you know, while it's far from perfect,

2:57

it is still the best test we currently have, uh, to save,

3:01

uh, lives from premature,

3:03

premature death from breast cancer.

3:05

And so with this in mind, um, let's turn to thinking about

3:09

where it can be helpful to take a step back

3:11

and think, you know, a step back from the daily grind

3:14

of the workstation, of the all the lists we have to cover

3:18

to remind ourselves, you know, why we screen why there are

3:22

so many different guidelines and putting the risks

3:24

and perspectives for ourselves

3:26

and also our patients and providers.

3:29

Um, because, uh, not only in in October breast, um,

3:34

breast Cancer Awareness month,

3:35

but also potentially in Women's History month,

3:37

may we get more questions about this, uh, or,

3:40

or really any day it's be it's good to be armed with it.

3:43

So, you know, first it's important to keep in mind

3:46

that the benefits of screening mammography include,

3:48

but are not limited to significant decrease in breast

3:52

cancer specific mortality.

3:53

This is really important to keep in mind.

3:56

Um, and in other words, why we screen

3:59

because to quote this 2021 JCAR article

4:03

about women at average risk for breast cancer, written

4:07

by a number of colleagues

4:08

and friends from the a CR Breast Cancer Screening Leader

4:11

group, I'm gonna quote this article

4:12

'cause I couldn't, you know, say it better myself.

4:14

So quote the a CR

4:16

and SBI recommend annual mammography screening beginning at

4:20

40, which provides the greatest mortality reduction

4:24

diagnosis at an earlier stage, better surgical options,

4:27

and more effective chemotherapy Delaying screening

4:31

until age 45

4:32

or 50 will result in an unnecessary loss of life

4:35

to breast cancer and adversely affects

4:38

minority women in particular treatment advances cannot

4:42

overcome the disadvantage of being diagnosed

4:45

with an advanced stage tumor.

4:47

And women who wish to maximize benefit will choose annual

4:50

screening starting at 40 years old

4:53

and will not stop screening.

4:56

Amen. So, um,

4:59

the A-C-R-S-B-I recommends annual screening starting at 40

5:03

and has done so for many years

5:04

because of diverse scientific evidence supporting this,

5:07

including considering each one, one by one in brief,

5:11

the randomized controlled trials,

5:13

national population based data, computer modeling

5:16

and international service screening data.

5:19

So this slide shows a forest plot from a Lancet

5:22

meta-analysis of every single randomized trial ever done

5:26

studying screening mammography, demonstrating

5:29

that the relative risk

5:31

of breast cancer death in women invited

5:33

to participate in screening was 0.8

5:36

or 20% lower in than women not invited

5:40

to participate in screening overall, even number one,

5:43

including the flawed Canadian trials, which flawed in

5:47

that they did a clinical breast exam

5:49

before assigning to women to screening or not.

5:52

So, not truly randomized.

5:54

Number two, even though all the randomized controlled trials

5:57

were done as early as the 1960s up to the nineties.

6:01

So all film obviously no digital, obviously no tomo.

6:05

And number three, even taking into account, um,

6:09

the inherent problems

6:10

of randomized controlled trials in general, including

6:15

the multiple reasons listed here.

6:17

The most important of which I would say are number one

6:19

and two, namely non-compliance, which means

6:23

that women in the case study group were, are invited

6:26

to have screening mammography.

6:27

However, a woman refuses to be screened

6:30

and does a breast cancer, she still counted in

6:33

that screening group, which minimizes benefit in the

6:36

screening arm and in contrast in contamination,

6:40

women in the control group who are not invited

6:43

to participate in screening,

6:45

but if they have a screening outside the the trial,

6:48

they're still counted as an unscreen control,

6:50

which would artificially improve the mortality benefit

6:54

in the non screening arm.

6:55

Does that make sense? I hope so.

6:57

That's why when we look at national population based data,

7:00

we see an even greater reduction in breast cancer specific

7:04

mortality than is demonstrated by the randomized trials.

7:06

In other words, as a result of the randomized trials,

7:09

randomized controlled trials screening mammography was

7:13

introduced at a population-based level in the United States

7:16

in the mid 1980s.

7:18

And though it was not then

7:19

and is still not now an official national screening program,

7:23

within a few years, the death rate from breast cancer,

7:25

which had been steady for decades, began to decrease

7:28

as demonstrated on this slide.

7:30

And specifically this slide shows a 38% decrease in US

7:34

breast cancer mortality from 1990 when the breast cancer

7:38

death rate was 30 73 0.8 per 100,000 women

7:42

to 2014 when the breast cancer death rate was

7:45

45.9 per 2000 women.

7:48

And two additional points about this, you know, um,

7:52

Hong Kong, uh, doesn't screen any of their women,

7:55

but has access to modern therapy

7:57

and the death rates are increasing there

8:00

in contrast to decreasing here.

8:02

And however, unfortunately, number two, the surveillance,

8:05

the epidemiology and

8:07

and end result program organizing this population data,

8:10

this the year registry does not make note of whether

8:14

with breast no does not make note of whether women

8:16

with breast cancer were screened or not.

8:18

This is obviously a major flaw.

8:21

Um, whereas data for international screening,

8:24

study service screening programs

8:25

and other countries do have this information.

8:28

And so when stratified by those who were actually screened

8:31

as opposed to just invited to screen,

8:34

as in the randomized controlled trial,

8:36

we see an even greater benefit,

8:38

an even greater reduction in breast

8:40

cancer specific mortality.

8:42

Um, look, here's this, uh,

8:43

the same graph now just extended out to 2020,

8:47

uh, just before covid.

8:50

Um, and so what about specifically

8:53

for women in their forties?

8:54

Well, if one assesses life years, a very common metric

8:58

or impact of disease, this JAMA 2015 article demonstrates

9:03

demonstrating the distribution of person years of life

9:08

loss due to breast cancer by age at diagnosis shows that,

9:10

as you can see here, the peak is at age 45 to 49.

9:17

And this met analysis

9:18

of the randomized control trials focusing on data

9:20

for women in their forties, specifically demonstrated a

9:24

statistically significant 18% mortality reduction,

9:28

reduction in breast cancer, specific mortality

9:30

in women in age group.

9:32

Furthermore, younger women,

9:34

including women in their forties, tend

9:36

to get more aggressive faster growing cancers.

9:39

So they should definitely be screened annually,

9:41

starting at 40 instead of bi-annually

9:43

or deferring start age to 45

9:45

or 50 as some organizations recommend

9:48

as we'll further discuss.

9:51

So screening starting at 40 is further supported

9:54

by meta analyses,

9:55

including this one based on case controlled studies from

9:59

service screening data from countries as far reaching

10:01

as Australia with some enrolling women in their forties

10:05

demonstrating a 49% decrease in breast cancer specific

10:09

mortality in those actually screened.

10:12

And while regular screening mammography results in a

10:15

substantial reduction in breast cancer mortality,

10:17

as summarized here again

10:20

as the 2021 A-C-R-S-B-I statement, you know,

10:24

finally really explicitly states, which is why I quoted it,

10:27

you know, mortality reduction is not the only benefit

10:29

of screening mammography.

10:31

And yet unfortunately, the a CR

10:33

and SBI are the only organizations

10:36

issuing screening mammography guidelines

10:38

to take these other benefits into account, including

10:41

morbidity reduction, because screening mammography finds

10:45

cancers smaller than they would be if detected clinically

10:48

when palpable women have the option

10:50

of smaller surgeries lumpectomy instead of mastectomy

10:54

and potentially avoiding the toxic effects of chemotherapy.

10:58

Furthermore, the detection

10:59

of high risk lesions is also an important benefit

11:02

to consider because it may change how patients are managed

11:06

more on the guidelines

11:07

for high risk women later in this talk.

11:10

And finally, the vast majority

11:11

of women have a truly negative mammogram

11:15

the vast majority of time.

11:16

And being reassured as such is obviously

11:19

enormously beneficial as well.

11:23

You know, note, um, perhaps in retrospect

11:25

that I've been specifically saying breast cancer

11:28

specific mortality, and this is a really important

11:30

distinction from all co cause mortality, which this

11:35

and other articles tried to use to show

11:37

that screening mammography doesn't decrease mortality.

11:41

So this, um, August JAMA internal medicine article concluded

11:46

that quote, and this was looking at a meta-analysis of, um,

11:50

randomized controlled trials for many screening tests,

11:53

not just screening mammography, uh,

11:55

but including screening mammography.

11:56

And the conclusion for all these different screening tests

11:59

was, quote, the finding of this meta-analysis suggests

12:02

that current evidence does not substantiate the claim

12:05

that common cancer screening tests save lives

12:08

by extending lifetime except possibly

12:11

for colorectal cancer screening with sigmoidoscopy.

12:14

Um, that's not my area of expertise,

12:16

so I'm not gonna get into it here.

12:17

But the point I wanna make is that it's futile

12:20

to use all cause mortality as an endpoint,

12:24

especially when extrapolating from small randomized control

12:27

control trials, because you must either have to follow up

12:31

for way beyond the observation time,

12:33

or you have to have way more participants.

12:36

In other words, if you did screening for, for ages 40 to 74

12:41

and looked at all cause mortality at age 50,

12:45

you would need a randomized controlled trial of a total

12:47

of 1.25 million women total for both arms

12:52

to show that reduction of 2.2% all cause mortality,

12:57

which only corresponds

12:59

to a mild 18% reduction in breast cancer deaths.

13:02

So the conclusion should have been, we are not able

13:06

to take changes in all cause mortality

13:08

because none of the trials are powered

13:11

to measure changes in all cause mortality.

13:14

Although the sigmoid sigmoidoscopy trials come close, um,

13:19

and life years gained should be a better statistic.

13:23

But the pa this paper, this jamma paper,

13:25

calculates the life time gained.

13:28

And in response to this JAMA article,

13:30

the Chief Scientific officer

13:32

of the American Cancer Society made the important point

13:35

that these cancer screening exams have never promised

13:38

to prolong an individual's, um, natural lifespan,

13:42

but rather to reduce premature death from cancer.

13:46

In other words, again, fully, you know,

13:48

determining whether cancer screening extends a life

13:51

would require an extremely large clinical trial

13:54

that would have to follow patients for a very long time.

13:57

And the trials in this newest study here

13:59

weren't book book weren't big enough

14:01

to look at all cause mortality.

14:03

And the chief scientific officer said, um,

14:06

if a person's life expectancy at birth was 80,

14:09

a cancer screening may prevent their premature death at 80,

14:12

at 65, but it wouldn't necessarily mean they live

14:15

to be 90 instead of the predicted 80.

14:18

No one is saying if you do cancer screening,

14:20

you're gonna live to a hundred years old.

14:23

So I think that's really well said.

14:26

So that's why we screen, which begs the question,

14:32

which begs a sip of water.

14:43

If the data are so overwhelmingly demonstrating the benefits

14:47

of screening mammography, then why are there

14:49

so many different guidelines out there, there, you know,

14:51

making it unclear for patients

14:53

and ordering providers alike what to do.

14:56

Um, and to quote, quote, a unique leadership book

14:59

that was recommended to me, um, by one

15:01

of my breast damaging colleagues at Cornell,

15:03

and first female chair of the American College

15:05

of Radiology Board of Chancellors, Dr. Gerald Lee McGinty,

15:08

she recommended this book by Brene Brown called Dare

15:11

to Lead Excellent book.

15:13

And I particularly like this, uh, quotation from it,

15:16

which is that, excuse me, quote, clear is kind,

15:19

unclear, is unkind.

15:21

So I ask you, does this look clear?

15:24

We have three different organizations

15:27

with three different start and three different stop ages

15:31

and three different frequencies.

15:33

And as physicians, we want ordering providers

15:36

and patients to make informed evidence-based decisions about

15:39

their healthcare and not feel like they're, you know,

15:41

randomly throwing darts to determine which guideline

15:43

to follow for something as important

15:45

as a vital health outcome.

15:47

And as I think most of us, uh, already know,

15:50

the ACR slash sbi, as I've been saying, their recommendation

15:54

for years has consistently been

15:56

for annual screening mammography starting at 40,

15:59

which is in contradistinction

16:01

to the United States Preventative Services task force

16:04

or prevent services as some like to call it, uh, which is,

16:09

um, as of this spring, as of May, 2023,

16:13

biennial screening, um, of women 40 to 74,

16:18

but previously since 2009, they were recommending

16:22

biennial screening of women 50 to 74.

16:26

And this is all also in contrast

16:28

to the American Cancer Society recommendation

16:31

for starting at age 45 annually,

16:34

but then potentially transitioning to biennial at 55

16:37

or continuing with annual.

16:39

And given these three different start ages, 40, 45

16:43

or 50 at intervals, one

16:45

or two years, this qualifies in my opinion as unclear

16:48

and thus unkind

16:50

and for clarity, uh, in 2017

16:53

as described in this publication in cancer that I wrote

16:56

with colleagues from the a CR Breast Screening Leaders

16:58

group, including, you know, real giants in the field

17:01

that I was fortunate to work with, Sickles Hendrix Vy,

17:05

we used ANet computer models to compare the A CR

17:09

American Cancer Society

17:10

and Task Force recommendations at the time where csnet

17:14

is the Cancer Intervention

17:16

and Surveillance Modeling Network.

17:18

And under the auspices of the NIH, which is part

17:21

of the US Department of Health

17:23

and Human Services, the National Cancer Institute has funded

17:28

CSNET to develop computer models about screening,

17:30

including screening mammography and computer models,

17:34

although not without limitations, as well attempt

17:36

to rectify some of the shortcomings

17:38

of the data previously mentioned

17:40

by applying consistent starting age is

17:43

and consistent screening intervals, both within

17:45

and across various models.

17:47

And in some, the purpose of this study was

17:50

to use csnet breast cancer models

17:52

to compare three major screening biography recommendation

17:55

for women of average breast cancer risk at the time the

17:58

study was performed in 2016 slash 2017,

18:02

and the principle finding was that the greatest reduction,

18:06

the greatest mortality reduction, not surprisingly,

18:08

is achieved with annual screening starting in 40

18:12

a nearly 40% decrease in breast cancer specific mortality

18:16

associated with the A-C-R-S-B-I recommendation, um,

18:20

in contrast to only a 23% decrease in breast cancer

18:24

specific mortality associated

18:26

with the task force recommendation

18:27

of biennial screening women 50 to 74

18:31

and a 31% decrease in breast cancer specific mortality.

18:35

Uh, somewhere in between for the AC

18:38

American Cancer Society hybrid recommendation.

18:40

And, you know, presumably, uh,

18:42

the May, 2023 task taskforce updated draft recommendation

18:46

of screaming women 40 to 74 ally, um,

18:51

you know, the, you know, presumably their, um,

18:54

mortality reduction would no longer be as low as 23%,

18:57

but clearly it wouldn't be as high as the nearly 40%, uh,

19:01

associated with the A-C-R-S-B-I recommendation.

19:04

Um, and a logical next step for research

19:08

in the future would be

19:09

to directly compare these recommendations, um, ideally

19:12

with updated csnet models.

19:14

So given these three mortality reduction results,

19:17

how can three different organizations have such

19:20

different recommendations?

19:21

In other words, how do different organizations come up

19:24

with different recommendations if they have access

19:26

to the same CSNET data, same csnet models,

19:29

the same randomized control trials,

19:31

and the same population-based data?

19:34

So the top reasons for this, I would say, are outlined here.

19:37

Um, first, the task force focused its data review on

19:41

randomized controlled trials.

19:43

You know, the rationale being that, uh,

19:45

randomized controlled trials

19:46

as we all learned in medical school, you know,

19:47

are the gold standard for research.

19:50

And yet recall from this slide, um,

19:55

that the, the multiple reasons why the randomized controlled

19:58

trials underestimate the benefit of screening

20:00

and actual practice.

20:02

So part of the difference in guideline has to do

20:04

with the task force focusing on limited and older data.

20:08

Second, both the American Cancer Society

20:10

and Task Force only count one benefit mortality reduction

20:13

and ignore all the other benefits

20:15

of screening we've discussed, including those listed here.

20:21

Yet, the American Cancer Society

20:23

and Task Force include all the risks,

20:26

false positives over diagnosis, all of which are non-lethal.

20:30

Third, not only that, but they, they being the task force

20:33

and American Cancer Society focus on these risks

20:36

and describe them as harms as we'll get into shortly.

20:40

And fourth. Um, you know, it undoubtedly there are political

20:44

and economic factors here as well.

20:47

Um, you know, recall that from from grade school

20:52

or uh, a high school, you know, this is relevant

20:55

for 2024 election year as well, you know, the three branches

20:58

of the US government, including the legislative branch,

21:01

which is Congress, and the federal law requires Congress

21:05

to produce a budget each fiscal year,

21:07

the set spending LI limits very reasonable.

21:10

Congress, as we know, has two arms, the House, um,

21:13

and the Senate, uh, the latter

21:15

of which has a health education, labor,

21:18

and pensions committee, um, which oversees the Department

21:23

of Health and Human Services, which oversees the NIH,

21:28

which oversees, uh, the National Cancer Institute,

21:32

which funds csnet

21:34

and the Senate also authorizes the agency

21:38

for he Healthcare Research

21:40

and quality, the A HRQ to convene the task force,

21:44

therefore, trying to put all the, the arrows together.

21:48

If Congress is required to limit spending,

21:50

then they're going to understandably value recommendations

21:53

which are fiscally more frugal as the task force are

21:57

as demonstrated by this graph from a value-based care

22:00

website based on 2010 data, looking at the annual cost

22:04

of screening mammography by screening strategy

22:07

and demonstrating the task force recommendation

22:10

of biennial screening of, of fif ages 50 to 74,

22:15

not surprisingly, costs significantly less on the order

22:18

of billions of dollars less than the a CR uh,

22:23

SBI recommendation of annual screening mammography.

22:26

And this 2010 bar, uh, showed

22:28

what was going on in actual PR practice in 2010, right

22:32

after the task force announced.

22:33

Its 2009 updated Rec of Biennial 50 to 74.

22:38

So it shows the current current at two in 2010 practice at

22:42

the time in which screening, uh, which, which screening 61

22:46

to 73% of women fif 40 to 84 was actually going on.

22:51

So clearly there are political

22:53

and economic factors influencing organizational

22:56

guideline recommendations, um, according to, uh,

23:01

largely in part who is in charge of the organization.

23:04

So for the task force, we, we looked at My, my Tree,

23:07

that's Congress, but what about the American Cancer Society?

23:10

And in preparing for this lecture, I got curious

23:12

and I went down the rabbit hole, uh, looking it up

23:15

and, you know, discovering that, um,

23:19

the American Cancer Society is to, to quote their website,

23:22

quote, a nonprofit organization

23:24

that is exempt from federal taxation.

23:27

Uh, uh, as this, um, we ensure donors money is spent

23:31

as efficiently and effectively as possible.

23:33

And apparently they, the American Cancer Society raises

23:36

nearly all of its money

23:38

through private individual donations, which quote helps

23:41

to ensure our independence.

23:43

But still, the question is who is making the decisions?

23:46

And according to their website, the Society,

23:50

the American Cancer Society is governed by a single board

23:52

of directors, which is made up of volunteers from the,

23:56

both the medical and lay communities,

23:58

and specifically the board of director is comprised

24:01

of five officers and 16 directors.

24:05

And the board is responsible for setting policy.

24:08

So of course, I then had to see who the officers are, guess

24:12

how many physicians there are?

24:14

One, the scientific officer, um,

24:18

a hematologist oncologist from the B Brigham.

24:20

So that's it. And

24:21

so since we're digging deep here into organizational

24:24

structure and composition, because for the reason

24:27

that it significantly impacts organizational policy

24:29

recommendations, you know, for, for, for full, uh, for full,

24:33

um, digging deep, what about the American College

24:36

of Radiology to balance it all out?

24:38

So in brief, for completeness, as you may know,

24:41

the A CR was founded in 1923,

24:44

so happy hundredth birthday last year, um,

24:47

with the stated mission that quote, the a CR is the voice

24:50

of our members, empowering them to service patients

24:53

and society by advancing the practice

24:56

and science of radiological care.

24:58

And, um, show of hands, how many of a CR members, um,

25:03

you know, the, the A CR is really our voice,

25:05

and while I can't fit the whole governing board

25:07

of chancellors, in on one side here is top leadership, um,

25:11

from the chair, um, to the speaker, uh,

25:14

obviously all physicians, all radiologists,

25:17

and even if I may note, um, one, uh, breast imager,

25:21

uh, Dana, Dr.

25:22

Dana Smith, and who's chair for radiology, uh,

25:24

at Ochsner in New Orleans

25:26

and is gonna be, um, the next,

25:28

I believe I got the title right, chief scientific officer,

25:30

uh, CEO for the a CR.

25:32

So, so third

25:36

reemerging from that rabbit hole.

25:37

And having considered why we screen

25:40

and different guidelines, let's now, um,

25:43

focus on putting risks into perspective.

25:48

But I'll take this, uh, this section,

25:50

pause to take another sip of water.

26:01

And, um, what, just

26:03

because I think we all get a lot

26:04

of questions about risk from patients and providers alike,

26:07

and we want to be able to sufficiently answer

26:10

and address these questions.

26:14

So along the lines

26:15

of clear is kind an important motto for me.

26:18

I'm also really big on clear definition of terms.

26:21

So if we clearly define the word harm used over

26:24

and over by the task force

26:26

as demonstrated on the next slide, I think it's reasonable

26:29

to conclude that harm is too harsh a term for most

26:32

of the sequela of screening mammography.

26:37

And yet the original 2009 task force recommendation article,

26:42

moving screening mammography to biennial screening 50 to 74

26:46

uses the word harm, harms

26:49

or harmed a whopping 61 times,

26:54

specifically the harms of

26:55

screening stated by the task force.

26:57

Include those underlined here,

26:58

including psychological harms, false positives

27:03

over-diagnosis and radiation exposure.

27:10

I would say that the top three risks

27:12

of screening mammography

27:13

that we get questions about from patients

27:15

and providers include false positives and over-diagnosis

27:19

and radiation exposure.

27:20

So I'm gonna address these one by one.

27:22

You'll note on this slide that I purposely use the word risk

27:26

not harm, because in medicine, again, we talk about risks,

27:29

benefit analysis, we talk about informed consent,

27:32

including a discussion of risks, not harms, risks, benefits,

27:36

and alternatives and verbiage is really important.

27:38

So taking each of these one by one, starting

27:42

with false positives, again, let's clearly define the term.

27:46

A false positive is a test result erroneously indicating a

27:50

particular condition.

27:52

It's a risk of any screening test.

27:53

It's not unique to screening mammography.

27:56

And as we know in screening mammography, it just means

27:58

that patients, you know, get a buyer zero,

28:00

or we're called for additional imaging evaluation,

28:03

a few additional mammographic images and

28:05

or an ultrasound usually to make sure everything is okay

28:08

or if needed close follow up

28:11

or a biopsy, all of which is certainly anxiety provoking,

28:15

but none of which I think it's fair to say, can compare

28:18

to the anxiety of dying for breast cancer.

28:22

As this cartoon suggests,

28:28

instead as this a CR infographic demonstrates out

28:32

of every a hundred women

28:33

who get a screening mammogram 90 will be

28:36

told their mammograms are normal.

28:37

Only 10 will be asked to return for additional mammograms

28:40

or ultrasound, of which six will be reassured.

28:43

Everything is normal. Two will be asked

28:45

to return in six months for a follow-up.

28:47

That's our birads three and two will be

28:49

recommended to have a needle biopsy.

28:51

birads four or five is shown another way, a larger, um,

28:55

you know, population based, uh, level.

28:57

For every a thousand women

28:58

who have screening MA mammography,

29:01

only a hundred will return for a additional mammogram

29:04

or ultrasound due to something seen on the screen.

29:07

61 out of the thousand will have additional imaging

29:10

and find nothing is wrong.

29:12

20 will find, will have found that, you know,

29:15

whatever the finding was, was probably benign

29:16

and be asked to return at six month

29:18

for short interval follow-up 19 will be re um, recommended

29:23

for, um, needle biopsy.

29:25

And five, um, will be out of

29:27

that a thousand will be diagnosed with breast cancer with

29:30

that five being somewhere in the two

29:32

to 10 per 1000 screenings range,

29:34

which is the our performance benchmark

29:36

for cancer detection and screening mammography.

29:39

Where within that, the,

29:40

there the range depends on whether it's an incidence

29:42

or prevalence round.

29:45

To get even more granular, this A-J-A-J-R article,

29:50

which draws on data from the task force.

29:53

Uh, publication has quantified the risk

29:55

of a false positive mammogram to be once every 10.2 years

29:59

for a women in her forties

30:01

and once in every once in every 16.8 years

30:03

for women in her eighties.

30:05

So if a woman has annual screening mammography starting when

30:08

she's 40 and continuing for as long as she's in good health,

30:11

this means she may be recalled from screening three

30:14

to four times in her life

30:16

and to adjust the risk of radiation exposure,

30:18

which is certainly a concern

30:20

we hear from patients on a regular basis as well.

30:23

The risk of a fatal radiation-induced breast cancer due

30:27

to screening mammography is estimated to be once in 76,000

30:32

to 97,000 for women in their forties

30:34

and once in too many years to estimate for women, 80 or old.

30:40

Next is over-diagnosis.

30:42

So again, let's clearly define the term

30:45

over-diagnosis is diagnosis of a D disease by screening

30:49

that would not have become symptomatic in a patient's

30:52

lifetime or cause the death of the patient.

30:56

And first, like over,

30:57

like false positives over-diagnosis is not unique

31:00

to screening mammography.

31:02

It's a risk of any screening test.

31:05

Second over-diagnosis cannot,

31:07

as you would imagine from this definition,

31:10

be measured directly leading to uncertainty regarding

31:13

how frequently it occurs

31:14

and a lack of consensus regarding how

31:17

to estimate the magnitude.

31:19

Third, by limiting screening by delaying age of onset

31:24

and or increasing the screening intervals

31:27

will not impact over diagnosis.

31:30

And this is a very important, um, and complex idea.

31:32

And this last idea was the motivation for this study,

31:35

which I conducted with colleagues from the A CR Commission

31:38

for Breast Imaging, in which we surveyed fellows

31:42

of the Society of Breast Imaging asking about biopsy proven

31:46

breast cancer that didn't receive any treatment

31:48

for whatever reasons and no natural history.

31:51

And what we found was that not surprisingly,

31:54

among nearly 500 untreated breast cancers

31:58

detected on screening mammography non spontaneously

32:01

disappeared or breast

32:03

and an unknown percentage

32:05

of these cancers could be over-diagnosis.

32:07

In other words, the indolent cancers that wouldn't go on

32:10

to kill the patient or present clinically in their lifetime.

32:14

But because all untreated screened detective cancers were

32:17

visible and still suspicious

32:19

for malignancy at the next mammographic evaluation,

32:22

delaying the onset of screening

32:25

or increasing the screening intervals

32:27

between screening should not reduce the frequency

32:30

of overdiagnosis.

32:32

And this is an important concept.

32:34

I I feel like that not that many people understand.

32:36

You know, state another way, including the task force.

32:40

If a woman starts screening at age 40,

32:43

an overdiagnosed lesion could be detected

32:45

and overtreated when she's 40.

32:47

However, if this woman instead starts screening at 50,

32:50

that same overdiagnosed lesion will still be visible

32:53

and will still be detected and still be

32:55

overtreated when she's 50.

32:57

Alternatively, she doesn't have an indolent cancer

33:00

and she didn't have a screen of 40.

33:01

She might be dead of the disease by 50.

33:03

So this is why limiting screening by delaying age of onset

33:07

to sound like a broken record

33:09

or increasing screening intervals is not gonna over,

33:12

not gonna impact over diagnosis.

33:15

But you know, patients by ask or

33:17

or you may ask, what about, you know, all the claims?

33:19

We hear that a high percentage

33:20

of breast cancers are overdiagnosed.

33:23

And unfortunately, articles such as this one by Lyer

33:28

and Welsh in the New England Journal

33:29

of Medicine now over a decade ago, decade ago

33:33

can substantially impact public

33:36

and sometimes medical perception with its erroneous claims

33:38

of substantial overdiagnosis accounting is this article

33:42

claims for nearly a third

33:43

of all newly diagnosed breast cancer.

33:46

And this New England Journal medical article is one such

33:50

example of medical literature, um, you know, which is, uh,

33:55

not scientifically valid.

33:56

And I I'd like to show this, uh,

33:58

newspaper clipping in the this era of alternative facts

34:01

and post truth to make the obvious point

34:03

that you shouldn't just blindly believe everything you read.

34:07

There is disagreement over the extent

34:09

of over diagnosis in breast cancer screening for sure,

34:13

but the case for high rates

34:14

of overdiagnosis rests on analysis such as these by Lyer

34:18

and Welch that were biased by lead time

34:21

and erroneous incidence trend trends.

34:24

And when properly analyzed data from both randomized

34:27

controlled trials and service screening studies

34:30

re retrospectively, respectively, respectively, excuse me,

34:33

indicate that the rate of Dover over-diagnosis

34:35

of screening mammography is more like 10% or less.

34:39

And here are just two reputable studies showing this, um,

34:43

decade after decade, including this article from piti

34:46

and colleagues from 2012 looking at European service

34:50

screening data with scientifically valid literature

34:53

concluding the, that the most plausible estimates

34:55

of over-diagnosis range from one to 10%.

34:59

And this is a more recent article in radiology in 2017

35:02

by Dr. Hendricks looking at US data also reporting a sub

35:07

10% over diagnosis rate.

35:09

And circling back to the earlier discussion about harms,

35:12

I would say that the real harm

35:14

is if women don't get screened

35:16

because of concerns about false positives or diagnosis

35:19

because then they run the risk of under diagnosis,

35:22

which can be fatal to that point.

35:25

At my institution at Weill Cornell,

35:27

we've also published a study looking back on all screening

35:30

mammograms 2014 to 2016

35:34

with the primary endpoint of determining the rate

35:37

of detection of breast cancer

35:38

and associated prognostic factors in women 40 to 44

35:42

and 45 to 49 years old.

35:44

And what we found was that women, 40

35:47

to 49 years old had overall an 18 per 0.8% were

35:52

actually 18.8%.

35:53

All the screen detected breast cancers that we were seeing.

35:56

And the two cohorts, 40 to 44

35:58

and 44 to 49 had similar incidences of breast

36:03

of screen detected breast cancer, 8.9 and 9.8% respectively.

36:08

And cancer detection rates within performance benchmark

36:11

standing standards supporting a similar recommendation

36:15

for both cohorts and the a CR recommendation

36:17

of annual screening starting at 40.

36:20

Furthermore, over 60%

36:22

of the cancers in this forties cohort were invasive,

36:26

so clinically significant disease.

36:28

So if we didn't screen women in their forties,

36:31

we'd be missing about 20% of our cancers,

36:33

which again would be significant under diagnosis.

36:40

Um, on the other side of the age span, you know,

36:43

in news about overdiagnosis, um, this is a article, um,

36:47

again from August of 2023 in the um, s of internal medicine.

36:51

This article, um, is from Yale, my al Mater.

36:54

It's about screening mammography.

36:55

So I was curious to see, you know, if anyone in

36:58

that division, uh, wrote it.

37:00

Um, 'cause I know the people in that division

37:02

and more, I guess a next than after a Cornell.

37:06

And in fact, no one, um, none

37:09

of these names were familiar at all.

37:10

So when I looked at the authors, uh,

37:13

'cause I wasn't even remotely familiar with any

37:14

of their names, it turns out that they come from the section

37:18

of general internal medicine, um, and, uh, the Yale Cancer

37:23

and Research Center, obviously of international deputation,

37:26

but again, not with,

37:28

with not a single breast imager involved.

37:30

And I say, uh, you know, again for this too,

37:33

because if you look at the composition of the task force,

37:36

its members again, are from multiple disciplines,

37:38

but not a single one as a radiologist.

37:41

And, uh, the other thing of note here is that

37:44

its conclusion also uses note the biased word harms, stating

37:48

that quote over-diagnosis may be common among older women

37:52

who are diagnosed with breast cancer after screening.

37:55

Um, and it's really in contras in contra contra distinction

38:00

to our experience in clinical practice, again at Cornell,

38:02

where we also reviewed screening mammography exams at our

38:06

institution from 2007 to 2013 with the primary endpoint

38:11

of determining the incidences of breast cancer

38:13

and associated prognostic features in women

38:16

75 years or older.

38:18

You know, the task force says there's insufficient evidence,

38:21

um, to recommend for

38:22

or against screening in this age cohort.

38:24

So we wanted to provide sub evidence based on our,

38:27

our real clinical experience, you know, in comparison

38:31

with the seer data based, um, that was used, uh,

38:34

in the internal medicine, uh, article, uh, shown here.

38:39

So from 2007 through 2013 at Cornell,

38:44

68,694 screening mammography examinations were performed.

38:49

And of these screening exams,

38:50

4,424 were performed in patients

38:54

75 years or older.

38:56

On the basis of these exams, biopsies of cancer is found.

39:00

This corresponded to a breast cancer detection rate

39:03

of 5.9 per thousand screening exams, which again,

39:06

is compatible with performance benchmarks for screening.

39:09

And approximately 85%

39:13

of these screen detected cancers in women in this over 75

39:16

cohort were invasive.

39:18

So again, clinically significant disease.

39:23

You know, as an epilogue, several years

39:25

after this 2012 infamous New England Journal Medicine

39:27

article was, uh, published by, uh, lyer

39:30

and Welsh, uh, Welsh actually had to resign from Dartmouth

39:33

amidst a plagiarism scandal.

39:35

And yet the New England Journal

39:37

of Medicine still refused to retract his article.

39:40

You know, I think as, as a side note,

39:42

this Bo bo begs the question,

39:44

how does this happen at the level

39:46

of our nation's highest level of medical journals, um, such

39:49

as the New England Journal of Medicine?

39:51

And I definitely as chief

39:53

of clinical imaging interested in this, um, this topic,

39:57

a whole other, uh, conversation.

39:59

But I'm definitely, uh, as interested as we think about

40:02

how articles, um, become published in peer-reviewed journals

40:06

and, um, you know, at the highest levels

40:07

and go on to impact not only medical,

40:10

but also light perception.

40:13

You know, despite this, while Welsh is still, uh,

40:16

added in terms of attacking screening mammography, um,

40:19

with this article that appeared just in September, 2023, um,

40:24

which among other things, um, so he,

40:27

he's talking about the new,

40:29

this is the 2023 task force recommendations moving, um,

40:33

biennial screening from 50 to 74 to 40 to 74.

40:37

Um, again, taking, wearing my editor's hat,

40:40

there are no references for many claims in this articles.

40:43

I assume this is to satisfy the five reference, um, uh,

40:47

limit of the the perspective, uh, column.

40:50

Um, you know, I,

40:53

but it leaves definitely leaves me wondering

40:55

how it passed peer review if claim

40:57

after claim is unsupported or if there was any peer review.

41:01

Um, the article, the perspective piece decries the models,

41:06

but I don't says mls,

41:07

but then also uses them repeatedly to make the points.

41:11

Um, so this is some of the, uh, many problems here.

41:16

But, um, I digress anyway.

41:19

As a final note about the risk of, uh,

41:21

radiation induced fatal cancer room annual screening

41:24

mammography from ages 40 to 80, it's estimated

41:28

to be a max of 25 per 100,000 women,

41:32

or 0.00025

41:36

and a risk, this risk is obviously far smaller than the

41:39

current NIH estimate of lifetime risk

41:42

of developing breast cancer for women.

41:44

For American women, specifically according to the NIH,

41:47

based on currents incident rates, 12.4%

41:50

of women born in the US

41:53

will develop breast cancer at some time during their lives.

41:56

This estimate means

41:57

that if current incidence rates stay the same,

42:00

a woman born today has about a one in eight chance

42:03

of being diagnosed with breast cancer at some time

42:05

during her life, which percentage wise corresponds with a 12

42:09

to 13% lifetime risk of developing breast cancer.

42:12

And this means that higher than average risk is anyone

42:15

with a greater than 12 to 13% lifetime risk

42:18

of developing breast cancer.

42:20

And specifically, as we know, the a CR defines high risk

42:24

as 20% or greater lifetime risk of developing breast cancer.

42:28

So, you know, what are the latest A-C-R-S-B-I

42:31

recommendations for women in this cohort?

42:34

It's good we're talking about this now.

42:35

Um, because, uh, this is a relatively due, um,

42:41

since last, uh, women's history, uh, month.

42:43

This is May 5th, 2023 JAC article with table one listing,

42:48

um, main actionable genetic mutations associated

42:51

with an increased risk of breast cancer

42:53

in alphabetical order from ATM to BRCA to TP 53

42:59

and table two from this article takes specific populations

43:02

at risk and compares the prior with the current 2023

43:07

A-C-R-S-B-I recommendations.

43:08

And the three main changes I'd like to highlight are,

43:11

number one, that genetic mutation carriers

43:15

and their untested first degree relatives can wait till 40

43:19

to start annual screening mammography if they start annual

43:22

screening MRI at age 25 to 30.

43:25

And I'm definitely seeing more

43:26

and more of this with the increased number

43:28

of high risk reading MRIs I'm reading

43:30

where there may be a genetic mutation carrier in her late

43:33

thirties, say, with multiple prior MRIs, but no mammogram.

43:37

You know, I'd be curious to know

43:38

if that's what others are seeing.

43:39

Clinical practice number two for women

43:43

with dense breast tissue, the current recommendation is

43:46

for annual MRI

43:47

or as an alternative contrast enhanced, uh,

43:50

mammography or ultrasound.

43:52

And I'm gonna come back to this because in a few slides,

43:54

because this is a big statement for MRI

43:56

and number three, all women should have a risk assessment at

43:59

25 instead of 30, which really makes sense.

44:02

And some women need to start imaging screening at 25 to 30,

44:05

so they should know this by 25 if

44:07

they're gonna start on time.

44:10

You know, what we hear from many of our patients, of course,

44:12

is that they don't have any known risk factor.

44:15

So why should be the, why should they take on any

44:17

of the previously aforementioned risks to which it could be,

44:21

um, helpful to recall

44:22

and remind that while some risk factors are modifiable

44:26

and others cannot sub, cannot be changed, the fact

44:28

of the matter is that 60 to 70% of, of patients

44:31

with breast cancer have no connection

44:34

to these risk factors at all.

44:35

So, um, even if they don't have any risk factors,

44:38

they should still be screened.

44:41

And finally, circling back to number two here, that

44:44

for women with dense breast tissue,

44:46

the current recommendation now includes for annual MRI.

44:51

You know, the question I wanted to throw out there for, uh,

44:54

further research or further, uh, uh, thought

44:56

after this new lecture is, and, and I don't know the answer,

45:00

but, um, is this reasonable

45:01

or feasible recommendation when 45%, um, nearly half

45:05

of US women over the age

45:07

of 40 have dense breast on the wonder?

45:10

On the one hand, maybe, yes, this is a si you know,

45:12

a scientifically valid recommendation

45:14

to optimize early detection

45:16

because we do know that MRI is the most sensitive.

45:19

On the other hand, how many women would this actually be

45:22

or asked another way from our perspective as breast imagers,

45:24

how many MRIs would this be for us to read?

45:28

So did this answer this question of, of

45:30

how many women are in the us?

45:32

Um, ages 40 to 80, in fact.

45:35

So I looked at, um, census data from 2021,

45:38

and if I add up, um, you know, all the, um, the women,

45:43

40 to 44, 45 to 49, 50 to 54, et cetera.

45:49

Um, I take my word with the math.

45:51

This is 65 million women in the US ages 40 to 80.

45:56

And if 45% have dense breasts, this corresponds

45:59

with 29 million women with dense breasts

46:02

or 21 million MRIs annually.

46:05

Yikes. So my next question is,

46:07

how many breast imagers are there in the United States

46:10

allowing for the fact that obviously we're not e evenly

46:12

distributed across all 50 states

46:14

and not all breast images read MRI?

46:17

And the best estimate I could find was from this 2005 a JA

46:21

article, a Portrait of Breast imaging specialists,

46:24

which states that the highest estimate of number

46:27

of breast imaging specialists at the time,

46:28

approximately 2,800, um, that was the number.

46:33

So that's 2025, nearly two decades ago.

46:36

Fast forward now to 2024, even if this is rounded up to 3000

46:41

and double, that's still, that's 6,000, you know,

46:44

these are my back of the envelope con, um, uh, calculations.

46:48

That would still mean 29 million MRIs divided

46:51

by 6,000, um, breast imagers.

46:54

Um, this would be 4,833 MRIs per breast

46:58

imager, um, per year.

47:00

So that sounds like an awful lot to me.

47:03

I don't know about you.

47:05

Um, and you know, just, uh, taking a,

47:09

a full view at the look of, um, breast density issues, um,

47:14

and associate insurance.

47:16

You know, no, this is not a political map, uh,

47:18

for the 2024 upcoming election.

47:20

Um, but rather a map which demonstrates that as

47:23

of this year, 38 states

47:25

and the District of Columbia have some form

47:28

of breast density notification legislation.

47:30

Half a mammogram, although not all law, require

47:34

that a patient be informed about her own breast density.

47:36

Some laws only require general notification about breath

47:39

density and some state laws are more similar than others.

47:43

Um, but there's no state to state standard from state

47:46

to state on what patients exactly are told

47:48

or how they will be performed.

47:51

And furthermore, it's not like all 38

47:52

of these states have associated appropriate, um, insurance.

47:56

You know, even if there is a state insurance law,

48:00

are all women covered

48:01

for supplemental screening for dense press?

48:03

The answer is resoundingly no.

48:05

A state insurance law does not necessarily apply

48:08

to all policies within the state.

48:10

Um, for instance, self-funded plans out of state plans

48:14

and national insurance plans may be exempt from state laws.

48:17

And then what about all the women without insurance?

48:20

So, you know, we're sur circles as best to the beginning,

48:24

you know, um, looking forward

48:26

to women's history month again, starting just to remind us,

48:29

and that, you know, we still really need continued research

48:33

to improve women's health, health outcomes, access

48:37

to healthcare, including for breast cancer, so

48:39

that more women's lives can be saved

48:41

and more women can make history in the future.

48:45

And with that, having considered everything on the stated

48:48

agenda, I'll conclude and I'll be happy to take questions.

48:52

Thank you for your attention.

48:55

Thank you so much for sharing your lecture today.

48:57

At this time, we will open the floor

49:00

for any questions from our audience,

49:03

and you can submit those to a, that q

49:05

and a feature at the bo at the,

49:09

uh, in the zoom box.

49:11

Um, Dr.

49:14

Arle, if you're able to open up that q

49:16

and a feature, if not, it's okay.

49:18

I can read any of that. Come in. Please,

49:20

Please do. I'm

49:21

no one aspect,

49:23

Not a problem. Um,

49:24

no question yet,

49:26

but you did get a compliment if

49:27

you want me to read that out loud.

49:30

Uh, thank you for all the time

49:31

and effort in this, that this must have required.

49:34

The information you provided will be very valuable in

49:36

advising patients and informing fellow

49:38

clinicians going forward.

49:41

Good. I'm glad. If it reached, you know, one person

49:43

and their patients

49:45

and providers, then it's a worthwhile hour.

49:48

I guess I actually have a question, uh, that, that, uh,

49:51

sort of reminds me is if we have people in our lives

49:53

who it's time for them to, to get screenings

49:57

and their adverse to doing so, do you have any tips to

50:01

help convince those folks to do this or

50:06

It's such a it's such a good question.

50:08

You know, I started studying screening mammography, um,

50:11

when I was a fellow back in 2009,

50:13

and I was in my early

50:14

thirties and I thought, oh, this is great.

50:15

You know, like, I'll study the literature, do some research,

50:19

and by the time I hit 40, you know, this will, uh,

50:21

will, it's all be figured out.

50:22

There'll be no more controversy.

50:23

Well, I'm in the second half of my forties, forties now,

50:27

and obviously this still is going on,

50:28

but what I like to say, um, to women in my cohort

50:33

or friends and family are, um, well, depending on the,

50:37

on the person, what I think they will respond best to.

50:40

There was actually a study out of NYU in New York City,

50:42

the first, um, author is Gian Lee,

50:44

and she looked at approximately 500 breast image across the

50:48

United States, um, the vast majority of which, uh,

50:52

you know, happened to be women.

50:53

And the question was, you know, if you recommend

50:56

to your patients annual, the A-C-R-S-B-I recommendation

50:59

of annual screening mammography starting at 40,

51:01

do you yourself practice the same thing?

51:03

And 98% of breast imagers not only, um,

51:08

recommended this, but also personally practice that.

51:10

And I said, and I I would be one of them.

51:13

I wouldn't miss a single year, um, for both, you know,

51:17

the professionally here, you know,

51:19

here's all the professional data, but, um,

51:21

and also personally as as a woman, I wouldn't miss a year.

51:25

And so I recommend the same thing for, um, my friends

51:30

and family.

51:32

And, you know, that personal connection

51:34

and personal recommendation, knowing

51:36

that you have all the data in the world, like

51:38

how are you sort sifting through it

51:40

and come, what are you doing for yourself?

51:42

I think, you know, that can be impactful.

51:45

Yeah, I love that. Excellent.

51:49

Okay, so we have a couple questions, uh,

51:52

in in clinical nature here.

51:53

So where are we in using AI generated density

51:56

estimation and practice?

51:59

Um, such a good question.

52:02

Um, you know, I think it's variable across states

52:06

and institutions for sure.

52:09

I think the important point is, um, why this question is

52:13

so important is like how, you know,

52:14

what's the downstream ramifications of using, you know, ai,

52:19

quantitative based, um, density measurements?

52:23

Will it more objectively

52:25

and consistently one hopes, um, define

52:29

what is dense versus not dense,

52:32

and then be better able to, you know, define the, the,

52:36

the quantity of this cohort

52:38

and then think more realistically about what's feasible, um,

52:44

for, you know, fair access to women in this dense cohort.

52:50

Gotcha. And

52:52

how about new abbreviated rapid breast MR protocols?

52:55

Is that gonna change the equation for MRI utilization?

53:00

I, I, I think so. I hope so for sure.

53:02

I mean, just anecdotally, at my institution at Cornell,

53:05

I feel like from months to month, week to week,

53:08

I'm seeing more and more, um, higher risk screening MRI

53:11

and as we have more,

53:12

we're only doing them in a certain cohort, uh,

53:14

like inpatients with a prior full negative MRI.

53:19

But as we have more of those, more

53:21

of those patients in our past, as we get to the present,

53:24

we're doing more and more abbreviated, um, MRI

53:26

and it's faster to obtain, it's faster to read.

53:30

And I still rarely come across a study where I'm like, oh,

53:32

I wish I had the full protocol.

53:34

Mm-Hmm. So if it's, um, if the technical fee of time

53:37

and the professional fee of interpretation are both shorter,

53:40

then it's gonna, you know, going back to the economics

53:43

of this and, um, I used to feel like I have to apologize

53:46

to talk about economics in healthcare,

53:47

and that's just the reality in which we practice.

53:49

Um, then it's gonna cost, uh, cost less

53:52

and if it costs less, then hopefully it'll be available

53:55

and accessible to more women. Yeah,

53:58

For sure.

54:00

Have you heard about any bills that may be moving

54:02

through states regarding screening now

54:04

that the U-S-P-S-T-F recs were out last summer?

54:10

Can you repeat the question again?

54:11

It's, I it's a good one. It's a complex one. Yep, sure,

54:13

Sure. Have

54:14

you heard about any bills that might be moving

54:16

through states regarding screening now

54:18

that the U-S-P-S-T-F recommendations were out last summer?

54:23

Yeah, um, I don't know.

54:25

Uh, and you can't quote anything specifically, um,

54:29

but I will say that there certainly are like, um, you know,

54:34

private insurance laws that may then, um,

54:39

or have in the past, um, contradict what, um,

54:44

you know, Medicare has to cover.

54:47

Um, and depending on the state level one

54:49

may override the other.

54:51

And also, whereas I mentioned there are 38, um,

54:54

states in the country

54:55

with state level breast density notification laws,

54:59

there also has been a bill at time at the federal level

55:03

about breast density notification.

55:05

So I think if that were to pass at the federal level, how

55:08

a bill, a federal bill about breast density notification

55:13

interacts with, you know, the task, um,

55:16

force recommendations, given that we saw

55:18

that all comes down from, um, the federal level Congress,

55:22

the Senate, et cetera, I think will

55:23

be very interesting to see.

55:24

You would hope that there would be, um,

55:27

consistency across recommendations

55:30

and insurance coverage for access.

55:33

Yes, for sure. Fingers crossed.

55:35

Yes, Crossed.

55:37

Did you, did you experience an increase in patient callbacks

55:40

when you were making the transition from film screen

55:42

mammography to digital mammography?

55:47

Um, a very good question.

55:49

Um, I feel like I'm just at the, well, one that was sort

55:54

of like over 10 years ago

55:56

and I was sort of at the cusp of the transition,

55:58

so I can't answer that specifically based on data.

56:02

I know that the FDA approved, you know,

56:05

tomo in 2011 slash 12,

56:09

and I'll say that in in Tom, in, in adopting tomo,

56:12

which is sort of like first we adopt, went from film

56:15

to digital, and then the next big step,

56:17

maybe like a decade later was from digital to using tomo.

56:20

I definitely think there was, you know, a learning curve in

56:23

that first year or so.

56:25

As with tomo, we saw more

56:28

and didn't have the previous tomo, uh, to compare it to.

56:32

Um, and yet ultimately over the longer term,

56:36

and now it's been over a decade since, um,

56:38

the FDA approved tomosynthesis, you know, the,

56:41

clearly the literature has shown that, um,

56:44

3D tomosynthesis mammography, um, not only

56:48

decreases the recall rate, circling back

56:49

to the specific question, but also importantly increases the

56:53

cancer detection, um, rate.

56:56

So I would, um, hypothesize that

57:00

during the transition from film to digital,

57:04

there may have been, you know, a transitional period in,

57:07

in which there were increased callbacks,

57:09

but that ultimately the benefits of digital, um,

57:14

ha have certainly outweighed that for many reasons,

57:16

including, um, the, the ability to have prior screenings

57:21

because it's all digitally logged.

57:22

And studies have shown there is a great study out

57:25

of U-C-S-U-C-S-F by, um, first author Jessica Hayward,

57:29

who was a, um, Cornell, uh, trained at Cornell as well.

57:33

And she talk, she, in this study, they talk about, um,

57:37

that if there are two

57:38

or more prior screening mammograms on file, um, the rate

57:42

of recall, you know, significantly decreases.

57:45

So I would say just from the aspect of digital cataloging,

57:49

um, that would be, you know,

57:51

having digital over film could potentially decrease

57:54

recall rates overall.

57:56

Right. Thank you. All right, we've got two more for you.

58:01

What do you recommend for women with dense breasts

58:03

who are underserved by mammography?

58:09

I'm not sure in what sense underserved is, um, meant.

58:13

Um, I, I'm just very transparent with, you know, women,

58:18

if they come back to my office, I

58:20

and I will show them their mammogram

58:22

and I'll just, you know, I'll explain

58:23

like, do you wanna see your mammogram?

58:24

Yes. Okay, well your mammogram is an X-ray

58:27

and breasts, um, you know, it's an X-ray

58:30

and we all have, you know, fat, which looks black, black,

58:33

and the fibro glandular frank,

58:34

or the breast tissue looks white and a a, a mass

58:37

or a tumor could also look white.

58:39

So you can see here, like if it's a complete white out,

58:42

extremely dense breast, like it could be hard, uh,

58:45

like it could be a limited test in

58:46

that we might not see something growing in there.

58:48

'cause it would be totally obscured.

58:49

Most people totally get that, that idea.

58:51

So I said, I will say, you know, to supplement this, um,

58:55

for women of average risk,

58:57

we can perform supplemental screening with ultrasound,

59:00

the benefits of which there are, you know,

59:02

no additional radiation.

59:04

Now of course there's some insurance

59:05

issues which complicate this.

59:07

Um, but I will, um, I will say to them like, I,

59:10

I can't speak to all the, you know, insurance

59:13

and financial concerns.

59:14

I completely understate understand these are valid concerns

59:18

and we have to answer them.

59:19

However, from my perspective as a physician, I just wanna,

59:23

you know, show to you the scientific evidence

59:26

and the rationale behind, you know,

59:30

what a test can

59:32

and can't do so that you, the consumer

59:34

understands the benefits, but also the limitations.

59:37

Um, and I'll say like,

59:39

and for myself personally, um, I do go ahead

59:42

and get supplemental screening

59:43

because I also have dense breast.

59:46

I don't say that with everyone, but mm-Hmm.

59:48

I feel like if that personal, um,

59:50

discussion is gonna take it to another level

59:52

and put that over their edge and put a patient over the edge

59:54

and it's gonna be beneficial for the healthcare,

59:56

like I don't, I I just go ahead and tell them

59:59

because that's what my goal is as. Yeah.

60:02

That's great. Okay, one more question.

60:05

Uh, can you recommend articles

60:07

or books for birads breast density estimation?

60:10

I have been researching on it with no yield on step

60:13

by step instructions.

60:16

Um, good question.

60:20

N uh, not off the top of my head,

60:23

but circling back to one of the early questions about like,

60:26

the use of a i, um,

60:29

and dense, uh, breast density, uh, estimations, you know,

60:34

if I were to try to go answer this question

60:35

as I get off this talk, I would go to, you know, PubMed, um,

60:40

and look for review articles, uh,

60:42

in the past five years on this topic and see what came up

60:45

and then, you know, look at the, at the sources

60:48

and go with a, you know, high impact journal.

60:50

And I think that would be a good place to start. Awesome.

60:54

Well thank you. We got through them all

60:56

and thank you so much for your lecture again.

60:58

That was excellent. We appreciate you being here.

61:02

Thank you for the opportunity to speak.

61:03

And, um, happy leap year today

61:06

and happy Women's History Month starting tomorrow.

61:09

Absolutely. Yes. And thanks everyone else

61:11

for participating in this Noo conference

61:12

and for, for all your great questions.

61:15

You will, uh, you can access the recording

61:17

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61:19

by creating a free MRI online account.

61:22

We'll also email out the replay later today

61:26

and be sure to join us next week on Thursday,

61:28

March 7th at 12:00 PM Eastern, where Dr.

61:32

Mark Goslin will deliver a lecture entitled Pulmonary

61:35

Thromboembolic Disease,

61:37

challenging the Conventional Wisdoms and Algorithms.

61:40

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61:42

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61:43

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61:46

Thanks again and have a great day.