Screening for breast cancer


Shieva Ghofrany: [00:00:00] All right. Back to my clinical stuff. I'm done with the jewelry for today, so this month of October. Two important clinical months. One is miscarriage awareness month, which is why last night Dr. Josh Herbs and I talked about recurrent pregnancy loss and it's also breast cancer awareness month. So tonight I'm gonna have an IG live with my friend and beautiful girl, Jordan Mandel, who is diagnosed at age 27 with breast cancer, and it's a beautiful. 

Important story for everyone to know as a beacon of what to do, how to do it, and hope so. You should join us tonight. So let's talk about some nuggets about breast cancer. Um, mostly about screening and self breast exams. So, As we know there are different ways to detect breast cancer. If we talk about mammograms, which is the x-ray test of your breast, where they squeeze your breast between two plates, which can be uncomfortable, and some women will say they don't wanna do it because it's painful, to which I would reply. 

I get it. It's [00:01:00] uncomfortable. You can always take an anti-inflammatory like ibuprofen ahead of time. The fact is that you're still better off, God forbid, finding your cancer early, because that will be far less painful than if you have to go through procedures and surgery. So that is my reason for doing it because as you know, I like things I can find and fix, and I am not one to believe that we will never get diagnosed. 

I am one to believe that if we get diagnosed early and we can fix things, that is our best, best, best bang for our buck. One in eight women before age 75 in America will get diagnosed with breast cancer. Should that be a scary statistic? In my opinion, no. It's merely a fact. We can editorialize and say, that's horrible, that's scary, that's terrible, but that's not gonna help us. 

So rather than editorialize and be scared, Because we know how I feel about fear. I implore, beg, invite you to look at it as the fact is right now, one in eight are getting diagnosed. Of course, there are things to decrease and modulate our risk. Alcohol consumption can increase our risk weight, can increase our risk.[00:02:00]  

Family history of breast. Ovarian, maybe pancreatic, maybe melanoma, colon cancer, endometrial, which is uterine cancer. These things can increase our risks. So you should be talking to your doctor about those risks. And whether or not that means you can consider genetic testing and not paying attention to your breasts, unfortunately increases the chance that you can catch things later instead of earlier where they can be diagnosed and dealt with at a much, um, easier stage. 

So again, one in eight women before age 75. , don't be scared. Let's be proactive. And here's how. Guidelines right now from the American College of ob gyn basically say that you should get a mammogram starting at age 40 every one to two years. There are wiggle room in the guidelines to start at 35. So some of the guidelines would advocate for a baseline at 35 and then every year after 40. 

Here are the things that I would like to tell you about mammo. Yes, they are uncomfortable. [00:03:00] Yes, they are radiation. Yes, they have false positives, meaning indications that there is something wrong where you have an abnormal mammogram, when in fact the vast majority of the time there's nothing wrong. Those are the negatives When people talk about the negatives of mammograms. 

Radiation, though the amount is relatively small and has not yet been found to increase the risk of cancer discomfort, which I don't wanna discount it, but I'm gonna discount it because it is what it is and false. Which lead to cost in the system, anxiety for the patient, and potentially biopsies, which controversially can lead to issues. 

Do I think that's true? I don't think so. I don't really know the data about that. Meaning I don't think there's good data saying a biopsy can cause harm, but that is what some people believe. Aside from that, yes, it increases anxiety to have to go through a test, but my view is net net, it's worth it. So let's walk through what happens with a mammo. 

Then we're gonna talk about self breast exam and then breast ultrasound. So mammogram again. You go to the [00:04:00] radiology department, they squeeze between, so your breasts, they send it to your doctor. If your breasts are very dense, meaning your breasts have fibro tissue and fatty tissue, if there is more. 

Fibrous tissue, which is a very common variant. It's not abnormal, it's just a variant. If you have very dense breasts, then it's harder for when the, the breasts get squeezed for them to see through the entire density. So they may suggest that you also do a screening ultrasound. So again, the mammogram, which is the screening test by definition, meaning you've walked in with no symptoms, no concerns, and you're just getting. 

And you might need an adjunct of an ultrasound as a screening test. Many states have mandated that that is considered a screening test and therefore should be paid for by insurance. So you should. Find out about your state and argue with your insurance if they try to decline it and if they try to claim that it is not a screening test, unfortunately it is not enough for your doctor to just say, oh, you have dense breast. 

Let me write for it. It has to be determined by the actual [00:05:00] mammogram itself and when the radiologist reads the mammogram. If you have a certain level of density, then you're considered dense enough to qualify for the screening ultrasound, and then insurance should pay for it. Let's assume that the mammogram comes back abnormal, which it does a lot, and there's varying levels of abnormalities. 

Many of which we can guess are going to still end up being benign. You might have architectural distortion they call it, where when they squeeze, I kind of describe it as they squeeze and there's still a little fold that isn't compressing out enough. So the doctor doesn't think there's something wrong, but they can't tell that there's nothing wrong. 

So you might get a call back saying, come back for spot compression, meaning in that one focused area, we will squeeze a little bit harder and see if that distortion compresses out. If it does, you are fine. It does not mean, oh my God, there was something that we just dodged a bullet. It means we couldn't see enough. 

We need to do a little bit more. Unfortunately, now you're outside the realm of a screening test because now the screening test has shown something abnormal and you need a diagnostic test, which [00:06:00] is the diagnostic mammogram. Why does that matter? Because if you have a high deductible like me, , then the diagnostic portion is not covered. 

It's not your doctor's fault. There's nothing your doctor can do about it. Your doctor would love to decrease the insurance premiums and everything, but they can't. There's no way I can call a follow up mammogram, preventative or routine or screening because it's not, it's diagnostic. It's like there's literally no way to do it. 

So that's, that's how that works. So you've had your mammogram, you get called back for an abnormality. You might have even had an ultrasound and a focused mammogram. Let's say for the sake of argument, they tell you you need a breast biopsy. The majority of breast biopsies like four out of five. Meaning 80% of breast biopsies will be normal. 

So about 20% of the breast biopsies will be irregular, which is a pretty good number. So if you get a call from your doctor or the radiologist saying, turns out you need a biopsy, I'm not gonna say don't be anxious cuz it is very anxiety [00:07:00] provoking. But I really do wanna encourage you to know that the likelihood is that it's still okay, and that is something that's really important to focus on because. 

Um, emotionally allowing yourself to devolve to the worst place in that moment is not going to be helpful. You need to be on your best game, keep your immune system high and boosted and get in and do the tests that you need to do so that if there is, there is something there. You are catching it early. 

Okay, so mammogram. Downside is radiation. Downside is a lot of false positives. Upside is that it will catch things very early. If you haven't felt anything and you're going for a screening mammogram, the likelihood is that even if you have cancer, which again is not very high likelihood, but if you have it, You're catching it early in a phase that is not yet stage three or four, most of the time, if you're catching it at the mammogram before there's something palpable, meaning something you can touch and feel, then you're catching it early. 

And the most important aspect that I maintain is that that means your life likelihood of longevity is [00:08:00] very high. So keep that into consideration because I know what it's like to be told. Oh, it turns out you have cancer and immediate. We have been taught and conditioned and thought modeled to go from you have cancer, therefore you think you're gonna die immediately. 

The fact is that we know that that does happen for certain people and that is a dreadful and terrible thought. But the other fact is that the majority of people who are finding breast cancer, if they're finding an early, are going to live a very long life. Okay? So that's really important to remember. 

Move on from the mammo. I'm gonna go out of order actually to the ultrasound before the breast exam. So the ultrasound is usually used in women who have dense breasts. Again, firm dense, lumpy, bumpy breasts. We might call them like, um, casually, they need an adjunct ultrasound that, like I said, insurance may or may not cover, though they should, that ultrasound sees things differently than the mammogram, so it's not enough. 

I have patients who say, I'm just gonna do the ultrasound instead of the mammo. You can do it. I'm never mad. I say all the time, I'm not gonna be mad at anyone. You can do whatever you want. I'm [00:09:00] here to inform you of what the right answer on the test and what I would tell my sister . So the right answer on the test is that ultrasound is different than mammogram. 

They pick up different things. Mammogram is an x-ray and so it will pick up small, little bright white spots that look different. Ultrasound will see totally different things. It is an, it is ultrasound technology. Sees, um, entirely different types of tissue, but sometimes can delineate something from a mammogram, so they cannot be either or. 

They need to be used in conjunction in women over 35 or 40. In younger women who have very dense breasts, mammograms are harder to actually read, and therefore an ultrasound might be something that's valuable in those women. We're talking about mostly women over 35 to 40 at this point. Let's say you've had your ma, you've had your mammogram, it came. 

Irregular. You then have an ultrasound. It came back a little irregular. You have your biopsy and it's turned out to be fine. The biopsy said there's nothing wrong. Then you might go back six months later for them to follow up on that spot and just make sure it hasn't changed because [00:10:00] no test is a hundred percent. 

But again, the likelihood of that actually representing cancer is small self breast exams. So self breast exams will either be called sbe, self breast exam, bse Breast Self-Exam, or bsa. Self-awareness. The differentiating factor seems to be, it's not very concrete in our world, but do you actually have to examine your breasts in a very specific way? 

Like where that card that many of us were given back in the day that hangs in your shower, where you look in the mirror, where you change positions, where you lie on your bed, where you do it standing up? Or do you have to just be aware of your breasts? And as American College of ob gyn a. Phrases it, it's really more of breast awareness. 

Well, what I tell my patients, because I think the yield is better when we don't make things such a big deal and so formulaic and so like it has to be done in a certain way. What I try to encourage my patients to do is get to know your breasts so that if something comes up that I feel or you feel. You know that it's either different or that [00:11:00] it's been there for a while, meaning the best time to check your breast is right after your period is finished. 

So if you can easily do that, great. For example, if you're on the birth control pill, what coincides with the end of your period tends to be the first day of your new pill pack. So while often say to my young patients, so they get into the habit, why don't you check your breasts the first day of your new pill pack, the day you open your new pill pack, just think to yourself, okay, I'm gonna check inside my bra, my armpits, and learn about my breasts. 

So we'll discuss how to do it in. If you are not on the pill and you can remember the end of each period, great. If you don't have your period or it's too hard to to remember, or your period's irregular, you could just pick the first of the month. It's not gonna be as accurate because cyclically throughout your period, your breasts will change. 

But it's better than nothing cuz the whole idea again is being aware of your breasts and how they generally feel so that when you go see your doctor and she examines you and says, oh, I feel a little lump. It's great. When patients can say to me, oh, Sheva, that lump has been there for years. I always feel it. 

It's no different than before. Or, oh, that's what they just saw on the [00:12:00] mammogram. Look at the rapport. It's exactly there. That's what they described. What's difficult is when I feel something or you guys feel something and you don't know if it's new. So try to get into the habit of getting to know your breasts. 

What I tell patients, and I'm not saying it's right, you should talk to your own doctor or be very thorough in your breast exam, but an alternative, the way I tell patients is in the shower, once a month with a little bit of soap on your hand, feel inside your armpit. Make circles around your breast with your arm up over your head so you can really feel it. 

I just can't do it with my phone. So arm up above your head, inside your armpit where you have the tail of your. Circles around your breast, superficial, deeper than deep, and all circumferentially so that you can get to know your breast so that if a new lump bump shows up, you calmly call your doctor hey, and discuss with her what you should do. 

The reason I say calmly is because I would estimate like 98% of the time when a patient feels something, it turns out to be nothing concerning. But we don't know that. So, you know, one [00:13:00] of my party lines. It's likely nothing, but let's check it out. And I kind of preemptively tell patients that if you think you felt something, even if I don't feel it, I might send you for an ultrasound anyway. 

Because in different positions at different, you know, different times where you've lifted your arm differently, you might have felt something that we just don't feel. So let's assume you have been checking your own breasts, you've had your mammogram, you've had your ultra. You might also be told sometimes to have an mri, magnetic resonance imaging, which is not radiation. 

It can see a lot in your breasts. It can also pick up, unfortunately, a lot of false positives. The benefit is that if you actually are in a high risk group, like either carry one of the genes and haven't had prophylactic surgery where you've had your breasts removed, or don't carry a gene, but have a lot of family history or incredibly dense breasts, you might be suggested to do a mammogram and ultrasound. 

Now, six months later an. Six months later, a mammogram and ultrasound so that essentially every six months you're getting surveilled so that if something comes up there has not been a long interval in between. Because again, [00:14:00] early detection is key. And keep in mind the MRI is not re uncomfortable because you have to lay prone on your front and you need a quick IV to get contrast that. 

It is not something I think you should avoid if it has been suggested and you discuss it with your doctor. Again, insurance does not always cover it and it's pretty expensive, so it's something you really need to decide with your doctor.