Mammogram Screenings: What you need to know with Dr. Laura Dean

Podcast Transcript

Scott Steele:  Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Hi everybody, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. We're absolutely pleased to have our guest, Dr. Laura Dean here today, who is in the diagnostic radiology department in the breast-imaging department. So Laura, welcome to Butts & Guts.

Laura Dean:  Thank you so much and thank you for having me. I'm pleased to be on the show.

Scott Steele:  We're always wanting to know a little bit about you before we delve into today's topic. where are you from? Where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Laura Dean:  Sure. I'm originally from Lexington, Kentucky, lived there through high school, moved around through medical school. I went to medical school in D.C. at George Washington University, did my intern year at Georgetown, and then I moved to Chicago. So, moved towards the Midwest, residency and fellowship at Northwestern in Chicago and then made the choice to come to Cleveland for the opportunity to work at the Cleveland Clinic.

Scott Steele:  Well, we are very excited to have you here, and today what we're going to talk about a little bit, has to deal with breast cancer and as many people may know, October is Breast Cancer Awareness month and there's more than 200,000 new cases of breast cancer that will be diagnosed in the United States alone this year. However, it's a part of what we're bringing you on for, advances in early detection and treatment really do offer a better chance of survival than ever before. So, we're going to focus on this today. You're in the radiology department and one of the first things that comes up is, oh, I got to get a mammogram or something like that. So what's a mammogram?

Laura Dean:  Sure. To put it simply, essentially, a mammogram uses x-ray technology. It's essentially an x-ray test where a woman's breast tissue is compressed between two plates. Typically a mammogram, a standard mammogram is comprised of four views, two pictures of each breast where the breast tissue is compressed. X-ray pictures are taken, and then the radiologist can look through those exams.

Scott Steele:  Let's say you, we're all built in different shapes and sizes. Let's say if you have smaller breasts versus larger breasts, is there a problem with mammograms, depending on the size of the breast or the makeup of the person?
Laura Dean:  It can certainly make it a little bit more challenging, but that's what our technologists are there for. They're extremely experienced. Our goal is that the mammogram experience is as comfortable for a woman as possible, because we want women to come back year after year. So, the technologist will really work with them to make sure that they're comfortable. There are lots of tricks that we have up our sleeves to, if for a patient who has very small breasts or the alternative, a patient with very large breasts, we certainly know how to accommodate that, because we want everyone to be getting screened.

Scott Steele:  So obviously, I'm a colorectal surgeon, so some of the questions that I may ask you may sound a little ridiculous and I appreciate you humoring me. My understanding is there's two types of mammograms, a traditional mammogram and then a 3-D mammogram. Can you talk to our listeners a little bit about each and what are the advantages and disadvantages of each of them?

Laura Dean:  Sure. The 2-D mammogram is basically the mammogram that I just described, where a woman's breast tissue is basically compressed between two plates. X-ray pictures are taken and we get two pictures of each breast. That is historically, the most standard type of mammogram. You can imagine if you're taking a three-dimensional structure with just the breast tissue, and you're compressing it into two dimensions, you have an overlap effect. That's inherent in mammography. One of its limitations is that you do have that overlapping breast tissue.

That brings me to the 3-D mammogram, which is, you can almost think of it, it's not the same, but almost like a CAT scan for the breast tissue, where the women's breast is still compressed in the same fashion, so still compressed between the two plates. But the machine actually scrolls across the breast tissue while the woman's breast is in compression. What that allows the radiologist to do, is basically scroll through that breast tissue, so it eliminates that overlap effect and the radiologist can see through the breast tissue with much more ease.

Scott Steele:  Was there any factors or other factors that would make you determine who would get a 2-D mammogram versus a 3-D mammogram?

Laura Dean:  Important things, not all women can tolerate the 3-D mammogram. It's a little bit more stressful on a patient's neck. They have to be a little bit more mobile. They have to be a little bit more flexible. Some women just simply aren't able to do it because of positioning reasons, but most women, again, the technologist will work with them so that they're able to tolerate the exam.

Really, 3-D mammograms have been shown to be beneficial for women of all breast densities. We may, throughout the course of this conversation, talk a little bit more about breast density because it is important, but 3-D mammograms have been shown to be beneficial for women of all breast density. While the standard 2-D mammogram is really the recommended test for breast cancer screening, 3-D has really been shown to be beneficial for all women in a screening population.
Scott Steele:  What a great segue you just gave me. Tell me a little bit about women's breasts densities.
Laura Dean:  We hear a lot about breast density in the news. It's very controversial. It's a very hot topic, including in the legislature. The reason that it's important, is because dense breast tissue we see on the mammogram, and it can have what's called a masking effect, essentially, where breast tissue can mimic or can overlie a breast cancer. A woman's breast is comprised of basically two different types of tissues. We have the more fatty tissue, which is dark on the mammogram, and then the connective tissue and the milk ducts, which shows up as white on the mammogram. That's where a dense breast tissue becomes a challenge, and a problem, is because cancer also can be white on the mammogram.

Scott Steele:  Let's go on a little bit about that, there are some listeners out there who have never had a mammogram. What can they expect when they go to get a mammogram? Walk us through that.

Laura Dean:  The visit really, and we try to keep it standardized across, certainly at the Cleveland Clinic, across all of our imaging facilities. Women can expect to come in, fill in an intake history form, similar if you go to any kind of physician or a specialist. We want to know about your breast health history, any family history, any problems or symptoms that you may be having. So, I always encourage women to think about those kinds of things before they actually come in for their appointment. It's just helpful information for us.

Another thing that we ask patients not to do is wear deodorant. Deodorants can actually give a little bit of an artifact on the mammogram. Something, that if you haven't had a mammogram before, a woman might not be thinking about that. But typically, the technologist will ask, "Are you wearing deodorant today?" That's why, because we can get a little bit of an artifact up towards the armpit area.

Scott Steele:  Is there any preparation for this? Do you have to do anything? Do you have to fast? You have to do anything like that?

Laura Dean:  Nothing. It's quick and easy. Just like any other doctors appointment you just show up.

Scott Steele:  One of the things we're going to talk a little bit about is screening guidelines and then the recommendations for how young, how old. Is there a start and a stop? It's my understanding that you're currently working on a research paper, talking about those lines. In addition to going into some of your research that you're doing and answer some of the screening guidelines, can you just give me the 50,000-foot view of when women should get screened and other factors that may cause somebody to get a mammogram or any breast imaging outside of those traditional screening guidelines?

Laura Dean:  Sure. We'll start with just what we know from basic decades of science, and that shows us that breast cancer and breast screening for breast cancer, specifically through mammography, saves lives. The science has shown us over years and years, that the most lives are saved when screening mammography is performed every year starting at the age of 40. It's been a little bit more controversial and there is a little bit more of a divergence in the guidelines recently in major women's health organizations, about exactly when screening should occur.

That's been a big topic of conversation, specifically for women in the age group between 40 and 49. At the Cleveland Clinic, what we have tried to do, is summarize and adopt those guidelines, so that we can guide our patients. What the Cleveland Clinic has adopted as our recommendation for our patients, is that a woman should have the option to start screening mammography beginning at the age of 40.

We do encourage a shared decision-making between women and their physicians. Then, from the ages of 45 to 55, we do recommend a yearly screening mammogram for all women. Then, at the age of 55, having a conversation with their doctor about whether they should continue every year or going to a biannual or every two-years screening schedule.

Scott Steele:  Do men need mammograms?

Laura Dean:  That's a good question. We do occasionally see men coming in for mammograms. A common reason that men come in is they have a symptom. If a man has gynecomastia or a palpable area or something tender behind, it's typically an area that's a tender lump behind one of the nipples. Most of the time these are benign. It's very, very common. But they will be referred to the breast center. What men might not be expecting is that the first test, and what's actually the most helpful is a mammogram. A lot of our men, our male patients are not expecting that, but we do quite a bit of mammography even in male patients.

Scott Steele:  You talked a little bit on the early end, in terms of 40 years old and then that that window between 40 and 50. What about the later cohort? In colorectal cancer, there's a debate about 80 years old or not. Should you get a colonoscopy on that? Is there anything along those lines in terms of mammography?

Laura Dean:  Similar discussions on the mammography front, and that is about to age 75 or that conversation with their doctor when they're expected to have 10 years of healthy life. So, around age 75, but it doesn't necessarily mean a hard stop at 75. It just means having that conversation at 75. Where do I see myself in 10 years? How healthy am I? What medical issues am I facing and that kind of thing to determine the most appropriate time to stop.

Scott Steele:  Yeah, I think it's important that we talk a little bit about, we're saying screening now. Can you talk about the person who actually has a finding of what they would get and what role does a mammography, and is there any other imaging tests or other things that people may eventually get from their physicians that would kind of roll into that?

Laura Dean:  Sure. There are two different main populations that we see, and those are either a finding that's detected on a screening. We hear a lot about women who are called back, so the call-back from a screening mammogram. Just the fact that a woman gets called back for a possible finding on a screening mammogram, a lot of those findings end up being just normal. Overlapping breast tissue, normal related to positioning, not necessarily something that's wrong inside the breast tissue. One of the common things that people will get for additional imaging is diagnostic imaging. That may be to help us problem-solve, to see is there a real finding in the breast tissue or not. That's from something detective on the screening side. On the diagnostic side, we see patients who are referred from their doctor for a symptom. Either they're having a new lump, a new area of thickening, an area of retraction in the breast tissue, something that they're feeling, a lymph node in their armpit, nipple discharge.

These are all symptoms that we commonly see for diagnostic imaging so that we can do more workup. A lot of the time we can answer those questions with just a mammogram and an ultrasound. We use ultrasound very commonly as an adjunct to mammography. There are other tests, such as breast MRI, which are used on a more case-by-case basis.

Scott Steele:  For those listening out there that want a mammogram or feel they need a mammogram, how do they go about getting a mammogram?

Laura Dean:  There are a couple of different ways. One simple way is just to request an order from your primary care physician or OB/,GYN at the time of your annual visit. Another thing that the Cleveland Clinic has really been advertising, we're trying to really increase access for our patients. One thing that we have done is implement walk-in clinics. There's a whole list of them. There are, I think we're up to seven locations now, if I'm not incorrect, throughout the region. They're listed on our website essentially, where patients can just walk in and not have to have a scheduled appointment. There are certain scheduled hours for those and those are posted on the website. But that's one way, where they can actually walk in at a time that's convenient for them.

Then, there's also a self-referral program, which is another way that we're trying to increase care. This may be for patients who don't yet have a plugin with a primary care physician or an OB/GYN or someone that can write an order. Those are patients who can actually walk in without a physician's order for a screening mammogram.

Scott Steele:  What's on the horizon for breast imaging out there? Are we going earlier? Is there any other tests that, is the mammogram going to go away one day?

Laura Dean:  That's a good question. I think that, certainly with the advent of 3-D mammography, I do think that 3-D mammography is becoming more and more standard of care. I do think that that may eventually, and a lot of practices and locations replace standard two-dimensional mammography because it's been shown to be really beneficial. Number one, in terms of decreasing the false positives or like we just discussed, those patients who are called back for having a finding that ends up being just normal, overlapping breast tissue. We've decreased the false positives of screening, which is one of the criticisms of standard mammography. Then we can also see better. So, we're also increasing cancer detection. Both of those are the main goals of screening mammography. There's a lot of talk about really continuing to identify who's at risk and who's high-risk of breast cancer.

So, for those patients, there's still a lot of debate about what is the best screening test, especially for those high-risk patients who may also have dense breast tissue. Identifying the high-risk patients and, then making sure that they're in a good screening protocol, and then deciding any adjunctive screening that may be on top of that.

Scott Steele:  As we close this out, what do you want women or men that are listening to this, some take-home points, things to really remember about this entire process?

Laura Dean:  The most important thing that I tell my patients every day, is that that the vast majority of breast cancers that we see, over 75% occur in women who don't have a family history of breast cancer. We hear a lot about patients who are at high risk or I hear patients say, "Oh this can't be a cancer. There's no cancer in my family. No one in my family has ever had breast cancer." What I want patients to understand is, that that's actually the opposite.

75% of cases that we see of breast cancer are de novo, with no family history. I think that's really important for patients to know. The other thing that I like to talk to my patients about is just breast self-awareness. We've heard a lot of debate about the efficacy of clinical breast exam or self-breast exam. What we like to tell our patients is just to be aware of your breast tissue. Know what's normal for you so that you can help to decide and help us to determine if there's anything new or changing, as early as possible.
Scott Steele:  We always like to end up with all of our guests, a little bit about yourself, so we wind up with some quick hitters. First of all, what's your favorite food?

Laura Dean:  Sushi.

Scott Steele:  What is your favorite sport?

Laura Dean:  Tennis.

Scott Steele:  What is your favorite place that you've been to on a trip or vacation?

Laura Dean:  Santa Fe, New Mexico.

Scott Steele:  What is the last nonmedical book that you've read?

Laura Dean:  I just finished it this week. It was Liane Moriarty, Nine Perfect Strangers.

Scott Steele:  Finally, for all of those outside of the beautiful Northeast Ohio region, what do you like about living here in Cleveland?

Laura Dean:  I love the seasons. As much as we hear about the cold of the winter, we do have four beautiful seasons and I love to be outdoors, really taking advantage of all of the seasonal activities.

Scott Steele:  Amen to that. To learn more about mammograms and breast cancer treatment or to find Cleveland Clinic walk-in screening locations near you, please visit clevelandclinic.org/mammogram. That's clevelandclinic.org/mammogram. M-A-M-M-O-G-R-A-M. To schedule a mammogram appointment with a Cleveland Clinic specialist, please call (216) 202-6451. That's (216) 202-6451.

Laura, thanks for joining us on Butts & Guts.

Laura Dean:  Thank you so much for having me.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.