Updates in Breast Cancer Screening
Radiologist Laura Dean, MD joins Butts & Guts for Breast Cancer Awareness Month to discuss commonly asked questions about screening for this disease. Topics include the recommended age for a mammogram, 2D vs. 3D screenings, breast cancer in men, and more.
Updates in Breast Cancer Screening
Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.
Hi, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I am super excited to have a returning guest. And for all of you Butts & Guts fans, I want to go back to October of 2019. You will have an opportunity to hear Dr. Laura Dean, a radiologist in the department of breast imaging here at the Cleveland Clinic. Dr. Dean, welcome back to Butts & Guts.
Dr. Laura Dean: Thank you so much for having me. It's a pleasure to be here.
Dr. Scott Steele: Great. And so we're going to talk a little bit about updates in breast cancer screening. And so for those that don't want to go back and listen to the old episode, first shame on you, but second of all, tell us a little bit about your background. Where are you from? Where did you train? And where did it come to the point that you're here at the Cleveland Clinic?
Dr. Laura Dean: Sure. So, Dr. Steele, I'm originally from Lexington, Kentucky. I did my medical school training at George Washington University in Washington, D.C. And then my residency and fellowship in radiology and breast imaging, I was at Northwestern University in Chicago. And then I've been with the Cleveland Clinic doing breast imaging for a little over seven years in this specialty. It's a great place to be.
Dr. Scott Steele: Well, we are super excited to have you here and thanks so much for coming back. So, just as a little bit of background, October is Breast Cancer Awareness Month. And next to skin cancer, breast cancer is the most common cancer among women in the U.S.
Here at the Cleveland Clinic, our experts are leading the way in breast cancer screening treatment and follow-up care. So, we're super excited to have Laura Dean here today to get an update on breast cancer screening. So, to start off with, who gets screened for breast cancer?
Dr. Laura Dean: That's a really good question. And the general answer to that, when we're talking about just the average risk woman in the population, we do recommend that screening begin at the age of 4 and then it really should be continued every year, as long as a woman is in good health. So, every year starting at the age of 40. And that's when we talk about just the average risk of breast cancer. For women who are deemed to be at higher risk of breast cancer, they may be candidates for earlier or more intensive breast cancer screening. And they can talk to their healthcare provider to help them determine that.
Dr. Scott Steele: So, I think one of the questions that comes up with a lot of different types of multidisciplinary treatment is can you tell a little bit about... You're talking about screening. What about if somebody feels something, or feels a nodule, or has a drainage, or something's there, is that screening?
Dr. Laura Dean: So, that falls into more of a category of diagnostic imaging. And it's just a nuance of a different order that the patient may need to have, but typically when a patient has a symptom such as a lump, or a change in their breast that they're worried about, they would come to see a radiologist. We would do real-time images with what's called a diagnostic mammogram exam, where we take mammogram pictures and then possibly do a targeted ultrasound for that area. That patient is usually evaluated by the radiologist and gets her results that same day.
Dr. Scott Steele: And just to be clear, it doesn't matter what age in that particular case, does it?
Dr. Laura Dean: That's exactly right. We see patients who are eight years old, all the way up to in their nineties. And so anyone who feels something that feels out of the ordinary, regardless of age, should get checked out.
Dr. Scott Steele: So, let's go back to screening, or to the main topic that we're talking about today. So, can you tell us a little bit more about the types of breast cancer screenings that the Cleveland Clinic offers?
Dr. Laura Dean: So, Dr. Steele, the two main types of screening tools that we use at the clinic are what we call the two dimensional, or just the standard mammogram images, and then we also use the 3D, or breast tomosynthesis. And those are really the two main screening tools that are used for our patients.
Dr. Scott Steele: So, are the type of these different screening tools suited for specific type of patients? Or you mentioned the past... Why would you use one versus the other or both?
Dr. Laura Dean: And that's a really good question that does come up a lot. And the answer to that is that the gold standard really is just the 2D, or the conventional mammogram images. The newer 3D imaging, or the tomosynthesis, is essentially a more in-depth view of the breast. And it is really especially beneficial for women who have dense breast tissue, which we hear a lot about in the news. So, especially women who are high risk, or have dense breast tissue, would be especially good candidates for the 3D, or the tomosynthesis, exam.
Dr. Scott Steele: So, are there different rates of accuracy amongst the different types of either patients? You mentioned dense breasts in the past. Or reasons why you're getting this in terms of screening? Is accuracy involved here?
Dr. Laura Dean: So, accuracy is a part of it. So, the 3D mammogram, or tomosynthesis, does have advantages that make it more accurate compared to just conventional 2D. And this is because a couple of things. So, first and foremost, it increases our visibility in the breast tissue. We can really scroll through a patient's breast tissue. So, it does increase the detection rate of cancer, which is the primary goal of doing screening in the first place.
And then at the same time, these 3D mammograms also lower the chances that a woman may be called back, or what we call the false positives. So, the two advantages are we have an increased cancer detection rate and also lowering the false positive rate. So, to answer your question, yes, it does tend to increase the accuracy of mammography.
Dr. Scott Steele: So, there's a lot of people out there that may not get a screening test because they don't want to waste their time, or they're scared of what it's going to show, or they're actually scared about what it involves. So, for those listeners who are maybe... and any one of those who have never had a mammogram and are due for one, can you walk us through what the patient experiences when they come to a facility and gets a mammogram?
Dr. Laura Dean: Sure. So, it's a pretty standardized process throughout all of our sites. And essentially the patient comes in, they register at the check-in window. We have a standard intake form that all of our patients are asked to complete. And this is a questionnaire asking them questions about their family history of breast cancer, if they have any cancers that run in their family, if they've had any abnormal breast biopsies, and so forth.
And then from there, they would be introduced to their technologist and the technologist performs the exam. So, the technologist would take the patient into the exam room where we have the mammogram, which is essentially a very specialized x-ray machine. And the technologist would work the patient through the exam, which involves compression of the breast. So, we hear a lot about women being worried about is the mammogram going to hurt, or having sensitive breast tissue.
And the technologists are really, really highly skilled at being able to get patients through these exams. And so usually it's a really pretty quick test. The test itself is just a couple of minutes. And then typically the way they get their results in a couple of days to a week or so, they will receive a letter in the mail from most of our screening sites, giving them the results of their screening exam.
Dr. Scott Steele: So, in the past few years, have you seen Cleveland Clinic advances in breast cancer screening, in terms of new technology? You mentioned the 3D. Or early detection, or accuracy, or speed, anything along those lines?
Dr. Laura Dean: So, really the main thing that's changed over the last couple of years and then since I spoke with you last in 2019, the main technology has been just an upgrade in the 3D capability that we have throughout the region. Since I've spoken with you last, we really have been able to upgrade the majority of our units throughout the region. And so most locations where a patient goes for screening, they will be able to have a 3D mammogram.
And just aside from the technology advances, we've really done a lot to try to increase access for patients. It's really important to increase access as much as possible so that patients can actually get to a screening site with ease. So, to do this, we've added walk-in screening sites and those are available throughout the region. And they're listed on our website. There are a number of locations and times that are on there.
We've also added the ability for patients to be self-referred, meaning that they can walk in a lot of locations without an order. MyChart scheduling has been rolled out across the institution for ease of scheduling. And so in addition to the technology advances, we've really been trying to make it easier for patients to get in general.
Dr. Scott Steele: That's fantastic stuff. And so I know there's a lot to these different screening ones, but can you give us a little bit of a broad overview about the benefits or risks of these newer breast cancer screening tools?
Dr. Laura Dean: So, I've alluded to it a little bit. The main benefit of the tomosynthesis, or the 3D mammogram, is that increased cancer detection, which really is the whole goal in that we want to be able to see as much as we can in the patient's breast tissue. And tomo has really, we call it tomo for short, has really increased our ability to do that. And then also decreasing callbacks, so decreasing the patient's chance that they may have to come back for another exam, which I know is inconvenient.
It may be an additional expense to the patient. It causes anxiety and stress, just as you alluded to a few moments ago. On the side of the risks, so the 3D mammogram, aside from all of the benefits, the main risks really... It does have a little bit higher radiation dose. So, in general, mammography is still a very, very safe, low dose of radiation, but the 3D mammograms have on average about one and a half to two times the radiation of a standard mammogram.
Dr. Scott Steele: So, it's time to play our favorite game, Truth or Myth. So, Truth or Myth: most women are diagnosed with breast cancer have a family history of breast cancer.
Dr. Laura Dean: And that one's a myth. And you can flip it on the opposite. So, in fact, most women who are diagnosed with breast cancer do not have a family history of breast cancer. What I tell my patients is about 75% do not have a family history, which is why it's really important for all patients to get screened, not just the highest risk.
Dr. Scott Steele: Truth or Myth: men cannot get a mammography.
Dr. Laura Dean: And that's a myth. We do mammograms in men. The most common reason that we do it is because a man comes in feeling a lump. And a lot of the time that's a benign finding called gynecomastia, which is just a benign growth of tissue behind the nipple in a man. And it's very, very common. We see that a lot. But even in our male patients, the first thing that we do is we start with a gold standard mammogram, which often surprises them.
Dr. Scott Steele: Truth or Myth: there's nothing you can do to lower your breast cancer risk.
Dr. Laura Dean: And that one is a myth. So, it is true that there is nothing you can do to specifically prevent breast cancer unfortunately. There are lifestyle modifications that can help lower the risk. And these are things like maintaining a healthy body weight. Typically, we talk about through diet and exercise. Eating a wide variety of fruits and veggies, limiting alcohol intake, stopping smoking, and those overall lifestyle modifications.
Dr. Scott Steele: Truth or Myth: it is still helpful to get breast cancer screenings after menopause.
Dr. Laura Dean: And that one's a truth. And the reason for that is because we know that breast cancer risk steadily increases as a woman ages. So, that's why it's really important to continue those screenings as long as a woman is in good health, because over the course of her life, that risk steadily increases.
Dr. Scott Steele: So, Laura, I'm proud to say here at the Cleveland Clinic, we are some of the leaders in terms of inclusiveness, as well as having a place, a role for diversity equity inclusion. So, can you talk a little bit about recommendations for our transgender patients? Do they get screened just like any other recommendations, or how do we approach that?
Dr. Laura Dean: So, we do and we actually in our department are taking great strides to try and make sure that our facilities are welcoming, that our signage is welcoming and neutral. And so that we're not offending anyone who might come in through the door. And those patients should still get screened and they can always talk to their healthcare provider if they have questions about which specific screening they are eligible for. But absolutely, it's really important that we incorporate all of the patients into our screening protocol. And we're trying to make our department very friendly and neutral on that ground.
Dr. Scott Steele: Fantastic. And so how do you see breast cancer screening tools advancing in the future?
Dr. Laura Dean: So, Dr. Steele, throughout the country, a lot of work has been done on what can we do to make breast cancer screening even better. So, some things that I think are really interesting in the future will show where they're going to go for the mainstream, but things like contrast enhanced mammography, possibly the more widespread use of breast MRI, which has a lot of promise, especially the new fast MRI sequences. Things like molecular breast imaging, where it's a nuclear medicine study essentially where they look at the breast tissue. So, these are things that people are looking at and researching. I think some of them show a lot of promise, but we just need to wait and see how they play out in the future.
Dr. Scott Steele: So, as you know, we like to end up with questions for your quick hitters to get to know you a little bit better. And since you did answer some of the standard questions we have here on Butts & Guts back in October 2019, a couple more questions for you. If we were to go into your car and turn on your music system, what would be playing?
Dr. Laura Dean: The Highway, country.
Dr. Scott Steele: And are you salt or sweet?
Dr. Laura Dean: Salt.
Dr. Scott Steele: What was your first car?
Dr. Laura Dean: Mazda Protege.
Dr. Scott Steele: Baby blue, or what color we're talking there?
Dr. Laura Dean: Kind of a rock gray.
Dr. Scott Steele: Oh, nice. Nice, nice. And then finally, what's the coolest place you've ever been to on a trip?
Dr. Laura Dean: I studied abroad in Australia and I think being able to travel through Australia was phenomenal.
Dr. Scott Steele: Fantastic. So, what's our final take home message regarding breast cancer screening for our listeners?
Dr. Laura Dean: So, Dr. Steele, I think it's just really important... With COVID and all of the challenges of 2020, we know that so many women postponed a lot of necessary screenings, including colon cancer and breast cancer. And we really want women to come back. We're seeing that they're coming back for their health care, which is wonderful. We're really happy to see that, but we just really want to reassure patients that it's safe to come to the Cleveland Clinic, that it's safe to receive healthcare. And if they've been postponing those screening exams, we really want them to come back in.
Dr. Scott Steele: Sage advice. And please remember, again, as we said, it is important for you and your family to continue to receive your medical care. And so please take the time to schedule a mammogram. Visit clevelandclinic.org/walkinmammo. That's clevelandclinic.org/walk, W-A-L-K, in, I-N, mammo, M-A-M-M-O to view all mammography locations, hours, and phone numbers, including as Dr. Dean said, those offering walk-ins screening mammograms for women with no breasts symptoms.
And rest assured, here at the Cleveland Clinic we're taking all necessary precautions to sterilize our facilities and protect our patients and caregivers. Dr. Dean, thanks so much for joining us on Butts & Guts.
Dr. Laura Dean: Thank you so much for having me.
Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.