Danielle Lee: Good evening Jacksonville, happy Saturday. Welcome to the conversation. I’m Danielle Lee, here with Dr. Ali Kasraeian. Dr. Ali, how are you today?
Dr. Ali Kasraeian: I am good. How are you today?
Danielle Lee: I am doing just fine. What’s going on?
Dr. Ali Kasraeian: So, welcome to the conversation, everyone. Today, I am very, very excited to do a show that I have been hoping to do for a long, long time. My mom has discussed topics similar to this in the past for when I’ve been away. But this is the first time I’ve been actually to do a show talking about breast cancer screening and breast imaging all in one show to this degree. And to join me on this show today is Dr. Rachel Brem, who’s a professor and vice chair of Radiology of Georgia Washington University in Washington. And she’s also the director of their breast imaging and interventional center. And she’s a world renowned expert in breast imaging. She trained at John Hopkins University and did a Fellowship in breast imaging and stayed there for a while until she moved to George Washington University. I’m beyond excited, we spoke just briefly before the show. And that conversation got me excited about how wide the breadth of our conversation is going to be this hour. So Dr. Brem, thank you for joining us.
Dr. Brem: Oh, it’s my pleasure. I’m delighted to join.
Dr. Ali Kasraeian: So, one of the thing that we were discussing right before starting was the controversies that always seem to surround cancer screening in general, but specifically breast cancer screening. What are your thoughts in terms of where we’re at in 2016, where with that controversy of when to start screening, how to screen, and how that constantly seems to change. And why you think that controversy seems to always … The pendulum seems, at least in my impression, seems to always fall in favor of less screening?
Dr. Brem: So, I’m, you know, delighted that we’re starting on this topic, this critical topic. And I think just [inaudible 00:01:59] background, it’s important for everyone to realize that there has been a 30% decline in deaths from breast cancer over the past two decades. So, we’ve seen a marked change and a marked improvement in survival of women with breast cancer. Early breast cancer diagnosis is a curable disease; it’s largely curable. Women with stage one breast cancer have a 95% survival. So, that’s a cure. And a lot of that improvement and advance has been due to screening. So, why all the controversy, why all the issues that’s going on?
Well, first of all, no matter who you read, whether it’s The American Cancer Society, the USPSTF, the United States Preventive Services Task Force, no matter who you read, that if you do not start screening at 40 and screen every year, more American women will die of breast cancer. Nobody disputes that. So, if we’ve had all this movement forward and that’s clear, then why all the controversy? Well, let’s start out with the United States Preventive Services Task Force.
First of all, they used old data and they didn’t report any new studies or any new information. They just took old data, put it together and came to the conclusion that if you’re over the age of 50, that you need to screen 140 women to save one life. As opposed to, 180 women to save one life. So, who decides what that life is worth? I mean I think it certainly … If it’s someone I love or someone you love, it’s important to screen and save that life.
In addition, there was no experts on that panel because they felt that it was a conflict of interest. And finally, they said, if you read their writings, that if you listen to their recommendation of screening mammography at the age of 50 and every other year after that, then they’ll save 81% of the women that are now saved from dying from breast cancer.
But that means that’s almost 20% of the women who die from breast cancer could have been saved and that’s not acceptable. It’s also important to remember that almost 20% of the women, so almost one in five women with breast cancer, is under the age of 50. And so, these younger women not only get breast cancer but they get a more aggressive, faster growing breast cancer.
So, it is very important to have screening starting at the age of 40 every year if we want to maintain the forward advancements that we’ve had in saving women from breast cancer. And if there’s one thing that I can share with your listeners today, it’s get your mammogram, start at 40 unless you have the family history when you might need to start earlier and that is the best way to save lives.
Dr. Ali Kasraeian: And I’ll tell you, you know, we see this in prostate cancer, breast cancer, and prostate cancer seem to be similar. And I think the key point that you made there is when people get diagnosed with breast cancer early, often it is the more aggressive disease so that if you waited until the later ages to get diagnosed, for some of these recommendations cite and put in their guidelines, it may be too late. So, in those populations, it’s actually of the utmost importance to catch the tumors when they’re earlier and smaller. And that’s where things like screening mammography shine because they can highlight things that may not be palpable.
Dr. Brem: That’s absolutely true and that’s the goal of screening mammography. It’s to find cancers before they become apparent either to the patient, to the woman, or to the clinician. So, you know, it just absolutely boggles my mind as to why they recommend this. And the only thing I can think of is that it’s saving money. But, you know, it’s losing lives. And on the spectrum of things, we’re here to try to save as many lives from breast cancer as we can.
The other thing about the USPSTF is that they said that if you do mammography, there are harms. And one of those harms is the anxiety that women will feel if they get called back for additional evaluation from a screening mammogram that might show something. Just because your screening mammogram needs additional evaluation does not mean that you have breast cancer. Quite the contrary, almost always, with fewer exceptions, additional evaluation will present in fact what you had was just something that needed to be further evaluated. And that in fact you don’t have breast cancer.
And even if you need a biopsy from these findings, a breast biopsy these days should be much like going to the dentist. Women do it, it takes less than an hour. It’s done with a needle with no anesthesia. IV anesthesia, just with local anesthesia and women, you know, often say to me, you know, “Dr. Brem, I can’t believe that I-, you know, that this is so straight forward and so easy.” And head back to their desk. Or to their home or to their activities of daily living. But these kinds of opportunities really save lives.
But one of the thing I want to say is that, you know, the USPSTF focus on the anxiety of a callback from a screening mammogram. And, you know, as someone who’s taken care of women with breast cancer for as long as I have, I can assure you that telling them that they might need an additional mammogram or ultrasound is far less anxiety producing than telling them they have metastatic breast cancer, which can’t be cured [crosstalk 00:07:42]
Dr. Ali Kasraeian: And I 100% agree with you and another thing that’s very reassuring, less than 10% of women who get called back after a mammogram has found something that needs a bit, a further investigation, actually have cancer. So, this further investigation is more than 90% of the time reassuring that nothing is going om. And I think that precision and accuracy of the imaging that we’ll talk about today that allows you to feel more comfortable that you don’t have cancer, in my eyes, is more common to that anxiety than being concerned that something may show up later on down the line. And there are studies that actually prove that.
Dr. Brem: Absolutely, and studies who have looked at the anxiety show yes, that if you tell someone they may have breast cancer and they need additional evaluation. Understandably, they may be anxious but it’s very, very transient and they become back to baseline very quickly. So, the opportunity to save a life far exceeds the need to, you know, to worry about a woman’s anxiety. And not only that but do we live in the Middle Ages where women are not empowered and not advocates to themselves? Let the woman decide and not government decide if she wants to know everything she can about having terrible early breast cancer.
Dr. Ali Kasraeian: And I’ll tell you, I live in the world of prostate cancer, so for us, you know, comparatively women are spectacular self-advocates. We fight hard to get prostate advocacy off the ground and when you kind of look, our advocacy months of September and November flank breast cancer awareness month. And you guys do a spectacular job and we herald the work that breast cancer has done in terms of advancing the personalization of the science of the disease. But also the personalization of the advocacy of the disease because a lot of the advances that breast cancer continues to make is on the backs of the advocacy that allows the research to do that.
Dr. Brem: That’s true. That’s absolutely true. And so, you know, it really is critical that women understand how important it is to get mammograms. And the other thing that your listeners really need to understand is that getting to the path of survival is-