August 20, 2025 • 31 mins
Radiologist Sue Jane Grosso-Rivas, MD joins cardiologist and clinical researcher Michael J. Koren, MD for Part Two of her Master's Series on breast imaging.
Dr. Grosso-Rivas talks about some of the complications that can occur during imaging, including dense breasts and their surprising prevalence. She also talks about new technologies in the imaging world, including contrast mammography and the use of AI in cancer detection. She finishes the conversation by talking about men's mammography and the increase in young-onset breast cancer in some populations.
This is part two of a two-part series.
Be a part of advancing science by participating in clinical research.
Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com
Listen on Spotify
Listen on Apple Podcasts
Watch on YouTube
Share with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.
Follow us on Social Media:
Facebook
Instagram
X (Formerly Twitter)
LinkedIn
Want to learn more? Checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com
Music: Storyblocks - Corporate Inspired
Thank you for listening!
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts Hosted bycardiologist and top medical
researcher, Dr Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence! And I've
been having a fascinatingdiscussion with my colleague
from medical school, Sue JaneGrosso-Rivas, and we've been
talking about many issuesrelated to breast imaging.
This has really been amasterclass and I want to thank
Sue Jane again for being part ofit.
You mentioned the breastdensity.
(00:33):
Does that change the basicrecommendations of yearly
mammographies or do you gostraight to other imaging forms
for those type of folks?
Dr. Sue Jane Grosso-Rivas (00:40):
Yeah, no.
What has happened in the pastfew years is that density has
become something that everybodyis talking about, right?
First it was get your mammogram, get your mammogram.
And then it was, oh, get yourmammogram.
But you also need to know ifyou have dense breasts, to the
point where now there are laws,There are federal laws that
(01:10):
exist that say that you mustnotify patients about this thing
called density.
What do you communicate?
You have to communicate inthere because we send lay
letters.
We send the report to thepatient, but they also get
something that's called a layletter and in that letter there
is actually a phrase or two thatis mandated by the government
that says you may have densebreasts.
(01:33):
This is what happens with densebreasts.
Dense breasts may obscure, sothere's a whole phrase that goes
into that.
So women now need to benotified about this thing called
dense breast.
And why is that?
Because, yes, dense breast canobscure, sometimes a tumor.
You know, mammography is prettygood at detecting breast cancer,
(01:53):
but when you start going intothe dense categories it starts
to lower the sensitivity ofmammography for breast cancer.
So some of those patients mayrequire supplemental screening
and we should start withultrasound first.
Right, because ultrasound isanother modality and it's been
shown that if you do mammographyand you add ultrasound, you
(02:16):
will pick up some more cancersthat you did not pick up by
mammography.
The next step would be do youhave to go to MRI?
Right, because MRI is going to.
But if a woman has average risk, should you be, should you
recommend MRI?
MRI is really more for thepatient that is either diagnosed
with breast cancer or has anincreased risk.
(02:39):
Most of the women with averagerisk.
You can stop after theultrasound.
Right, you're done.
You've done everything you needto do.
But as a radiologist, I stillmaintain the ability to decide
what I think that patient needs.
So I may look at a mammogramand I may describe what I would
call a complex parenchymalpattern, and what I mean by that
(03:03):
is that when I look at herbreasts, not only is she dense,
but I see nodules here, nodulesthere, like masses, or I see
lines.
I just see that she's verycomplex and I know that I feel
that that patient really needsto go to MRI next.
So the radiologist alwaysmaintains the ability to be able
(03:25):
to say what needs to be donenext.
Dr. Michael Koren (03:27):
Approximately what percentage of women have
this dense breast phenomenon?
Dr. Sue Jane Grosso-Rivas (03:32):
Well, according to what you know, the
lexicon, meaning the AmericanCollege of Radiology, and
they've done a lot of studiesabout 40% of the population, oh
wow.
So there are four categories.
It's A, B, C, D.
A is completely fatty.
B is what we call scatteredfibroglandular, which is just
(03:53):
25% of this tissue.
Right, that becomes kind ofwhite.
C and D are heterogeneouslydense, which is 75% of the
tissue is there and extremelydense is.
You know, almost all of it iswhite.
So when they look at this, theysay 40% of women have dense
(04:13):
breasts.
They're in the category C or D.
Now I will tell you that certaincommunities have more dense
breasts than other communities.
So if you go to certain partsof the country, right, it could
be body habitus, some women, youknow, when there is some
obesity, right, those women tendto have more fatty breasts.
(04:35):
And when you have women, youknow, maybe in a population
where everybody's exercising,they're on hormonal replacement
therapy, you know, they're verythin, they watch their weight
those women are not going tohave as much fat in their
breasts.
Now, density is determined bygenetics.
You're either dense or you'renot dense.
But it also is affected bywhether you have hormones,
(04:57):
whether you exercise all thetime there's no fat, so on and
so forth.
But it was funny because when Iwent from Staten Island and
came to where I work now, it wascomplete.
I could not believe how manywomen were dense.
So I would say it's not 40%.
In my neighborhood, in mycommunity where I am now, I
would say 60 to 70% of women aredense.
Dr. Michael Koren (05:19):
Really, and that's in New.
Jersey right
Dr. Sue Jane Grosso-Rivas (05:21):
Yeah New Jersey.
When, of course, sometimes youmay have heard New Jersey
supposedly has a higherincidence of breast cancer,
because that's the other thing.
It's like going to differentparts of the country you find
different incidence of breastcancer and the population in New
Jersey is very large; a lot ofbreast imaging centers in New
Jersey.
Dr. Michael Koren (05:42):
And the epidemiology of breast cancer
when I was doing internalmedicine was that if you had
your first child later in life,you're more likely to get breast
cancer.
Is that still considered to beaccurate?
Dr. Sue Jane Grosso-Rivas (05:52):
Yes, they still use that and this
risk assessment that I told youabout.
That's some of the questionsthat they ask.
They will say have you hadchildren?
When did you have your firstchild?
Right, so if you had your childyounger although they say like
less than 20 is is mostprotective, I mean most women
are not going to have it at thattime.
But, um, so what?
(06:13):
Also, when did you have yourmenstruation, your first
menstruation?
It's like the earlier you hadthe menstruation, the more risk.
Uh, when did you have menopause?
The later you have menopause,the more risk.
So those questions are allasked in the risk assessment.
So that's still all part of it,but the single most important
thing is just being a woman andgetting older.
(06:36):
I mean that's why you need toget checked out.
Dr. Michael Koren (06:40):
So this is fascinating.
I'm loving all this information.
Thank you for sharing it.
So there's two more things onmy mind that I want to cover.
One is AI that's what everybodytalks about, and the other one
is men.
We'll make that last, buthopefully not least.
So, lets jump into AI, andcertainly AI is the buzzword,
and it has affected differentareas of medicine.
(07:03):
I like to tell my staff herethat for every incidence of AI I
see an incidence of ASartificial stupidity, and I
don't know if you want tocomment, but we've heard that it
is having a big effect inimaging overall and maybe
particularly breast imaging.
So tell us a little bit aboutwhat's happening with AI.
Dr. Sue Jane Grosso-Rivas (07:22):
Sure, you know, Mike.
What's interesting is I metwith a colleague the other day
and her son happens to be inmedical school right now and
she's a radiologist.
So she thought that radiologywould be a wonderful field for
her son and her son said no, mom, AI is taking over, I'm not
(07:43):
going to go into radiology, Iwon't have a job.
So very interesting for me tohear that that is what they are
possibly hearing right At thatstage of medical school where
it's affecting whether people gointo radiology or not, because
they're so concerned that AI isgoing to take over.
So artificial intelligence,right, what is it doing?
(08:04):
Well, look, is it good.
There's good and there's bad,always right.
So with AI and we had somethingbefore AI we had something
called CAD, which wascomputerized assisted diagnosis,
right, or computerized assisteddetection, and we now have CAD.
We've had CAD for years, years,and what the CAD does is it
(08:27):
helps to point out, for example,where there are calcifications,
because calcifications may bethe sign of early cancer, ductal
carcinoma in situ it's only inthe ducts hasn't invaded.
So, as a radiologist, one ofthe things we look for is
calcifications, but sometimesthey're very tiny, they're very
difficult to see.
So the software will pick upwhere there are calcifications
(08:48):
and it puts a mark around it andit says look here, look here.
And that saves you sometimes,right, because the radiologist
somehow didn't see it because itwas so tiny.
So we've had that for a while,because it also even picks up
masses or distortion.
But now AI is around and thereare quite a few radiology
(09:08):
practices that have it already.
So I just want to talk about thebreast imaging part.
So tomosynthesis right, that'sthe one I told you about that
slices through the breast andthere are several images.
Now one breast could have 80something images.
Like we don't realize.
We went from four images of thebreasts to now having, you know
(09:31):
, 80 images of one breast, 80images of the other breast.
I mean it gets to be almost toomuch all the slices that you
have to look at.
So AI for us, what it does, it'sgot an algorithm that has been
developed over time.
Right, these companies makethem better and better with time
because they feed them withinformation of you know, this is
(09:51):
what a cancer looks like.
You feed them all thisinformation and now this
algorithm comes along, looks atthe images, those 3D images, and
it says here it is, there's acancer right there.
There's a cancer right there.
Look here, look here, look here.
And there have been somestudies that are saying that AI
is picking up some cancers thatthe human eye has not picked up.
(10:14):
Right, we're only human.
Sure, you know we're we couldpossibly not see a subtle
finding.
Do I think AI has replaced theradiologist?
Not yet, not not at this point.
I have AI for one of theoffices and what'll happen is
it'll point to something for me,but ultimately it is the
(10:35):
radiologist that has to look atthose images and evaluate it and
decide is AI being stupid rightnow or is it really something?
And then you decide whetherthat patient has to come back or
not.
So I think we need to learn howto live with AI in our world.
Basically.
Right.
Dr. Michael Koren (10:53):
So we're certainly not at a point where a
radiologist or a group or aprocess that doesn't use AI is
somehow behind the times.
Right, we're not at that point.
Dr. Sue Jane Grosso-Rivas (11:04):
You have to be with the times, for
sure, and you have to learn.
You know, with every newtechnology that comes along and
we haven't even talked aboutcontrast enhanced mammography,
which you probably probablyshould mention, but with every
technology that comes along, youhave to kind of embrace it, you
have to look at it and you haveto see, well, how does this
help me?
You know, how can I use this tomake me a better physician?
(11:27):
What can this do for me?
And that's kind of the way thatI'm looking at it.
I'm towards the end of mycareer, so I'm not worried that
AI is going to replace me.
Dr. Michael Koren (11:35):
I think, based on the way you look,
you're at most halfway through.
Dr. Sue Jane Grosso-Rivas (11:39):
Yeah, Okay, Okay, Mike, let's just
say that that's true.
But I mean, I enjoy what I do,so I'm not going anywhere
anytime soon.
But yeah, no, AI is here andand you know it's.
It's going to be interesting tosee what happens in the future
with AI, because it's also goingto be used for magnetic
resonance imaging.
It's being used in manydifferent areas of radiology at
this point, so it remains to beseen.
Dr. Michael Koren (12:00):
So you mentioned contrast imaging, so
go ahead and give us the quickspiel on that.
Dr. Sue Jane Grosso-Rivas (12:05):
Okay, so we talked about x-rays being
static, but you know, contrastenhanced mammography and MRI
with contrast is not static,it's more functional, it's more
physiologic.
You know, with contrast agents,if you put either iodinated
contrast IV for contrastenhanced mammography, it's the
same IV contrast that they usefor CT scans.
(12:31):
Or if you use a radio tracer,like for positron emission
tomography, all of these typesof studies, the agent goes into
the body and it goes to aparticular place where for
positron emission tomography,it's where they're using glucose
.
With contrast enhancedmammography and magnetic
resonance imaging it's aboutflow.
Cancers develop blood vessels.
(12:52):
That's what cancer does.
Cancer wants to grow, so thevessels are created and it grows
.
And guess what?
The blood flow goes to thatcancer and then it shows up.
So contrast enhancedmammography means I'm doing a
mammogram but I'm giving yousome contrast because I want to
see the flow.
(13:12):
I don't know, I don't want tosee white.
They're subtraction images andit's going to show me where
there is a lot of blood flow.
And where there is a lot ofblood flow is where there's
going to be a cancer, and that'sthe same thing with magnetic
resonance imaging.
Contrast enhanced mammography'sgoing to be a cancer.
And that's the same thing withmagnetic resonance imaging
Contrast enhanced mammography isgoing to take off.
(13:32):
That's one of the newesttechnologies and they have a
study going on right now.
It's called the CMIST trial.
It's basically GE, togetherwith, you know, actually Estee
Lauder company.
I forgot the name of it.
I think it's called BreastCancer Research Group, I think
it's called.
So they've come together andthey are looking to see if women
(13:57):
with dense breasts, withaverage risk, will benefit from
contrast enhanced mammography.
And that comes up and shows usthat it is a good study.
I think we're going to see alot more of that for sure.
Dr. Michael Koren (14:08):
Wow, fascinating.
Dr. Sue Jane Grosso-Riv (14:09):
Because , it's easier.
Contrast-enhanced mammographytakes about anywhere from five
to eight minutes, whereasmagnetic resonance imaging takes
more like 30 minutes 35 minutes.
And MRI is very expensive.
Contrast-enhanced mammographyisn't.
So there are a lot of prosbasically for contrast enhanced
mammography.
But having said that, nothingbeats breast MRI.
(14:32):
Breast MRI is still at the topas far as being able to show
invasive breast cancer.
Abbreviated breast MRI is oneof the newer technologies where
they've learned that they don'thave to do the study for as long
.
They just have to do one or twoimages and they get to see what
they need to see.
So it's much shorter scan time.
Dr. Michael Koren (14:53):
Interesting.
So, last but not least, men andbreast imaging
Dr. Sue Jane Grosso-Rivas (14:57):
oh men, yes, yes, and I do get to
see a few men in my practice.
Dr. Michael Koren (15:01):
The forgotten sex, go for it.
Dr. Sue Jane Grosso-Rivas (15:05):
Yes, well, for the men, only 1% of
all breast cancers are in men,you know, whereas women, the
number of invasive breastcancers that may be shown this
year maybe, you know, greaterthan 300,000,.
Let's say a man, the men willhave breast cancer, maybe 2000,
you know of all the breastcancers.
So it's not common.
It happens as they get older.
(15:27):
So most of the breast cancersyou see in men are over the age
of 60.
Men do not get screeningmammography.
Okay, that hasn't beeninstituted.
The way that men present isthat a man will feel a lump.
When they feel a lump onclinical, or if the doctor feels
a clinical on clinical exam,they feel a lump.
(15:48):
That's when they end up comingto me.
I will do a mammogram on a man.
Okay, they have enough breasttissue to be able to do a
mammogram and we're looking forcancer.
Generally.
The difference, you know, orwhat we're looking for basically
in men, is they feel a lump.
Is the lump cancer or is itsomething benign, like
(16:10):
gynecomastia, which is thedevelopment of breast tissue
which does happen with a lot ofmen as they get older.
Also, many men that haveprostate issues.
They're on certain medicationthat affects the breast tissue,
they start to develop breasttissue, just like women.
Okay, so that's usually whatI'm trying to evaluate.
(16:30):
And you know, sometimes doctorswill send the man for an
ultrasound, but the ultrasoundis not what we need.
We need the mammogram.
You have a lump, you getmammography.
Now what if a man has a geneticmutation?
Because this is the other thing.
People used to think that yourmother's history was the only
history that was important.
That's not true.
(16:51):
Now we want to know your familyhistory on your mother's side
and your father's side, becauseyour father could have the
mutation.
Dr. Michael Koren (17:00):
Yeah, makes sense.
Dr. Sue Jane Grosso-Rivas (17:01):
If the father has the genetic
mutation, then that's going toincrease his risk for breast
cancer, as well as his children.
So, yes, and men don't getscreened, but men do well If
their breast cancer isidentified.
They usually get identifiedearly because men don't have a
lot of breast tissue, so it'svery easy to feel you know the
(17:24):
cancer basically.
So men do tend to do well.
Dr. Michael Koren (17:28):
Yeah, In the cardiology world we use a drug
called spironolactone quite abit that causes gynecomastia and
if we identify that, is that areason to get a mammogram or
just get them off thespironolactone?
Dr. Sue Jane Grosso-Rivas (17:41):
What ends up happening is that they,
you know it doesn't feelcomfortable for a man when they
start, you know, because whathappens is they develop breast
tissue and they'll developtenderness, which is
uncomfortable.
So sometimes what ends up isyou'll have to get them on
something else, some othermedication, basically you know,
Dr. Michael Koren (17:58):
But they don't necessarily need to be
imaged, I guess, is my question.
Dr. Sue Jane Grosso-Rivas (18:06):
He has to be imaged.
Dr. Michael Koren (18:07):
he has to be Okay.
Oh, interesting,
Dr. Sue Jane Grosso-Rivas (18:08):
If you, if you feel a lump and he's
on spironolactone, there's noway to know if the lump is
because of the spirono lactone,with gynecomastia, or is there
cancer.
Dr. Michael Koren (18:13):
Or if there's no lump, just enlargement of
the breast.
Do you still recommend amammogram?
Dr. Sue Jane Grosso-Rivas (18:17):
I would still do imaging.
I would do imaging, yeah.
Dr. Michael Koren (18:20):
Yeah, well, I'm going to be sending you some
referrals then in the nearfuture, all right, that sounds
good.
Dr. Sue Jane Grosso-Rivas (18:25):
So you know
one thing I do want to mention,because you're a cardiologist
what about arterialcalcifications on a mammogram?
Have you heard about that?
Dr. Michael Koren (18:35):
I've heard of them.
I'm not sure exactly what Iwould do, but I do get a lot of
referrals from other imaging tocardiology because of concerns
about coronary calcium.
But go ahead.
I'm sure you see that as well,yeah.
Dr. Sue Jane Grosso-Rivas (18:48):
I mean it's very interesting
because when I look at amammogram and I'm looking for
calcifications, sometimes I seevascular calcifications, so
breast arterial calcifications.
Now, let's say it's a woman,that she's in her 40s and I see
a lot of calcifications in her.
You know vessels.
I do report it.
Not all radiologistsnecessarily report it, but we
(19:08):
all know that there does seem tobe some association with, uh,
having vascular calcificationseen in your breast.
There seems to be someassociation with cardiac disease
and also the potential fordeveloping a stroke.
So you know, as a woman getsolder, you'll see vascular
(19:28):
calcifications more right,because basically she's
developing calcificationseverywhere, which includes the
breast.
So it is something to mentionand maybe it's an opportunity
for the primary care physicianto sort of look at that patient
and start assessing.
You know, how is this person'scardiac health?
Because ultimately we'retalking about breast cancer,
right?
But the leading cause of deathin women is still cardiac
(19:50):
disease right.
Dr. Michael Koren (19:52):
So A lot of women forget that, unfortunately
.
Dr. Sue Jane Grosso-Rivas (19:54):
Yeah, no, it's like, you know, breast
cancer.
And breast cancer is not eventhe leading cause of death.
It's lung cancer still, butbreast cancer is still the
leading cancer.
We should say but so, yeah, soif there are arterial
calcifications of the mammogram,we shouldn't totally ignore
them, because that may help todetermine if she has some
(20:16):
cardiac disease.
Dr. Michael Koren (20:17):
And I'm going to throw my final question out
at you a little bit out of leftfield, but it's something we've
addressed here in MedEvidence.
What are your thoughts aboutalcohol and breast cancer risk?
Dr. Sue Jane Grosso-Rivas (20:37):
Well, I think, like with anything, as
far as risk is concerned theyalways askhow can I , " "Reduce
my risk of breast cancer, right?
So you're going to hear fromany doctor for any cancer, right
?
Lifestyle you know.
Obesity they say with obesitythere's an increased risk.
You know.
You want to eat well, you wantto exercise, you know all of
(20:59):
these things.
But then yet I can tell youabout my very good friend who
was at the age of 40.
She was a runner, right.
She drank, you know, greenjuice or whatever it is she was
doing.
She had cancer, right.
So it doesn't just because youdo all these things doesn't
necessarily protect you.
Alcohol, from what I've heardand actually I was listening to
one of your podcasts, I thinkfrom Med Evidence, and I did
(21:20):
hear you guys talk about alcohol, but everything in moderation
is the way I feel.
I feel to say to someone don'tdrink alcohol at all.
I don't think that makes anysense, Just like, you know,
don't drink coffee, right?
If a patient comes into me,she's got multiple cysts.
(21:40):
We know caffeine can affect thebreasts and they could end up
developing more cysts.
But are you going to tellsomeone, well, you've got to
stop caffeine.
You know completely.
Very hard to do, I think ifsomeone's drinking alcohol on a
daily basis, that's too much andI do think that that is of
concern.
So, yeah, no, I would say.
Dr. Michael Koren (21:57):
All good things in moderation is the
lesson.
Dr. Sue Jane Grosso-Rivas (22:02):
I personally think, all good
things in moderation, but westill don't know exactly what's
causing the breast cancer.
Right, I already told you thatmost of it is not genetic that
we know of, although every year,right, every time, we hear
about more genes, more genes,and I, for example, we haven't
really talked about stories.
I have so many stories ofpatients, but a friend of mine,
(22:23):
his daughter, just passed awayat the age of 34 from metastatic
breast cancer and there'snobody in the family, just
nobody in the family.
So why, you know those, thosecases that I know of where
there's no?
And then I have another personwho's uh, was a technologist of
mine, you know developed DCIS ata young age and no genetics,
(22:45):
nothing.
And then her daughter, at theage of 31, finds her own, feels
her own breast cancer, okay,saves herself, basically.
No genetics! So so what's goingon, so you know, and and we
didn't get into is that we arefinding we didn't talk about
black women and there's a bigproblem that's going on.
(23:06):
And the ACR has now actuallyissued some new recommendations
and this is very important tosay right now which is that all
women should have their riskassessment at the age of 25 to
30.
And what that means is that whenyou go in to see your, you
should go in to see your primarycare physician, because a lot
(23:27):
of women don't know that thereis this genetic predisposition.
We need to know if there isfamily history.
You know how many times I talkto a patient and they don't even
know their history and whenthey find out there's something
abnormal, they go back and starttalking to all their family
members and then they find outoh yes, aunt so-and-so, cousin
so-and-so.
They start finding out all ofthese histories.
(23:49):
Well, that's what the newrecommendation by the American
College of Radiology you got tofind out by the age of 25 to 30.
And why?
Because if there is a geneticpredisposition or significant
family history, that woman mayneed to start earlier than 40 to
get her mammogram.
That woman may need to getbreast MRI, for example.
(24:11):
Right, and what they found isthat something is happening
within the black women, the agesof some of them, because you
can get cancer between the agesof 20 and 29.
It's not common but you can,and what they found was that
black women are getting the 50%more cancers in in black women
from the ages of 20 to 29 thantheir white women counterparts
(24:36):
Right 30 to 39, it's only aboutmaybe 17% increase.
Something is happening and manyof the black women get the more
aggressive type of breastcancer.
It's called triple negative,meaning it's ER negative, pr
negative.
You know, estrogen,progesterone negative and HER2,
herceptin negative.
They are much more aggressivecancers.
(24:56):
So you know, it's almost youknow, a warning that's going out
there to let everybody know.
Hey-
Dr. Michael Koren (25:01):
Any theories as to why that is?
Out of curiosity?
Dr. Sue Jane Grosso-Riv (25:04):
They're looking into the possibility.
They want to look at the typeof cancers, the molecular basis,
but what they have foundoverall not even just black
women, asian women, right, theyhave a lower incidence in
general, but they're findingthat the younger women are
starting to have more, there'smore of an incidence of breast
cancer, and people are trying tofigure it out.
(25:26):
And a lot of these breastcancers are estrogen receptor
positive and progesteronepositive also, so they tend to
be estrogen type tumors, right?
So I don't know, we haven'tfigured out exactly what is
going on.
But then let's go back tolifestyle.
That's what I'm saying.
So what is it?
So, if you ask me about alcohol,you know, is it related to the
(25:50):
way you're living your life,right?
Is it related to the way thatyou're eating?
Is it nutrition?
Is it the environment?
What do we have in ourenvironment?
The microplastics?
I don't know right.
There's got to be.
There's something that'shappening.
The good news is that for thepast 50 years, the mortality
rate for breast cancer hasdropped significantly.
(26:13):
So there is no doubt that weare doing a better job with all
of the screening, mammography,maybe the new chemotherapies
that are out there.
Whatever it is that we're doing, it is much better.
Women are surviving breastcancer.
There's no doubt about it thatthey are.
Whether it's stage zero, stageone, stage two, women can still
(26:34):
survive their breast cancers,absolutely so that's the good
news.
Dr. Michael Koren (26:39):
So, Sue Jane, a lot of people are concerned
about the cost of health care.
Tell us a little bit about whatthe expectation should be of a
woman who needs these screeningprocedures and what her
insurance company should pick upand what the cost should be
approximately.
Dr. Sue Jane Grosso-Rivas (26:54):
Well, you know, at this point,
because all of theseorganizations have agreed that
screening mammography shouldoccur, right, they should be
able.
Their insurance company shouldbe paying for their screening
mammography.
Dr. Michael Koren (27:08):
Zero out of pocket usually?
Dr. Sue Jane Grosso-Riv (27:10):
Usually a zero out of pocket, usually.
Now they may have, however, adeductible that they have to
meet, right?
So I shouldn't say everybody,everyone's insurance is
different.
Let's talk about Medicare, forexample, right, medicare.
Like most women that come fortheir mammograms, many of them
are older, they're Medicare age.
So the woman must know what theMedicare rules are, because you
(27:35):
know if they come just a fewdays too early, you know if it
has to be exactly at 12 monthsthat they can get their
mammogram.
If not, then they will beresponsible for the bill, right?
So they need to be aware.
Some insurance companies willsay you don't have to wait a
whole year, just do it at somepoint in the year.
So it just has to be, you know,this year, next year, it
(27:57):
doesn't matter what month.
Every woman has to be aware.
Now there are screening programsout there.
You know that that will pay forfree mammographies.
And you know in in New Jerseythere's something called the
seed program and that seedprogram will help women get
mammograms for free.
So there are ways of gettingfree mammography.
(28:17):
But as far as insurance isconcerned, yes, you're right,
this is something you need tolook into because if that
insurance company believes thatyou should only get mammography
every two years.
They may not pay for every year, right.
But what about supplementaryscreening?
Your radiologist reads it andsays you need an ultrasound and
(28:37):
your insurance company turnsaround and says, no, you don't,
right, that's a problem.
So you need to know what stateyou live in and you need to know
what the laws are, becausethere are states where the law
does protect you and theinsurance company has to pay for
your supplementary study.
The only way to know is tospeak to your insurance company.
(28:58):
Many women go back and fightwith their insurance companies
if they have to.
Breast MRI is another issue.
Sometimes you hear breast MRI.
Well, we can't get theinsurance company to agree to do
the breast MRI.
So I'm very careful in myreports.
I make sure that I make it veryclear as to why I am
recommending this breast MRI,because that report is going to
(29:18):
help determine whether herinsurance company will pay for
it.
But you're right, you have to.
And how about this?
When should you stop doing amammogram?
And I'm sorry we didn't get totalk about this, but this is
important because manyorganizations will say stop at
74.
I mean 74-year-olds say, 75, Imean nowadays people are living
(29:41):
much longer, right?
So the American College ofRadiology says this, and I
believe this as well you stopwhen you are no longer going to
be in good health.
If you're going to be in goodhealth for the next 10 years,
then you should continue to getyour mammogram.
So if you got a 74-year-old andshe's doing very well and she
(30:05):
expects you know, the doctorfeels like she's probably going
to live until 84, then yeah, sheshould continue getting her
mammogram, right.
So, but what if the insurancecompany doesn't pay for it?
That's a problem.
Dr. Michael Koren (30:18):
Well on that.
I truly want to thank you forthe MedEvidence family for a
true tour de force.
Thank you, Sue Jane, for a truemasterclass on breast imaging.
I learned a tremendous amount.
I'm sure our audience willshare that sentiment quite a bit
.
And thank you for sharing yourstory about Ms.
(30:40):
Goldberg.
And thank you for just atremendous number of very
pragmatic insights that I'm surewill make a difference in
people's lives.
Dr. Sue Jane Grosso-Rivas (30:48):
My pleasure.
My pleasure Any opportunity Ihave to get information out
there.
I just think it's what I'm hereto do.
Announcer (30:56):
Thanks for joining the MedEvidence podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts Hosted bycardiologist and top medical
researcher, Dr Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence! And I've
been having a fascinatingdiscussion with my colleague
from medical school, Sue JaneGrosso-Rivas, and we've been
talking about many issuesrelated to breast imaging.
This has really been amasterclass and I want to thank
Sue Jane again for being part ofit.
You mentioned the breastdensity.
(00:33):
Does that change the basicrecommendations of yearly
mammographies or do you gostraight to other imaging forms
for those type of folks?
Dr. Sue Jane Grosso-Rivas (00:40):
Yeah, no.
What has happened in the pastfew years is that density has
become something that everybodyis talking about, right?
First it was get your mammogram, get your mammogram.
And then it was, oh, get yourmammogram.
But you also need to know ifyou have dense breasts, to the
point where now there are laws,There are federal laws that
(01:10):
exist that say that you mustnotify patients about this thing
called density.
What do you communicate?
You have to communicate inthere because we send lay
letters.
We send the report to thepatient, but they also get
something that's called a layletter and in that letter there
is actually a phrase or two thatis mandated by the government
that says you may have densebreasts.
(01:33):
This is what happens with densebreasts.
Dense breasts may obscure, sothere's a whole phrase that goes
into that.
So women now need to benotified about this thing called
dense breast.
And why is that?
Because, yes, dense breast canobscure, sometimes a tumor.
You know, mammography is prettygood at detecting breast cancer,
(01:53):
but when you start going intothe dense categories it starts
to lower the sensitivity ofmammography for breast cancer.
So some of those patients mayrequire supplemental screening
and we should start withultrasound first.
Right, because ultrasound isanother modality and it's been
shown that if you do mammographyand you add ultrasound, you
(02:16):
will pick up some more cancersthat you did not pick up by
mammography.
The next step would be do youhave to go to MRI?
Right, because MRI is going to.
But if a woman has average risk, should you be, should you
recommend MRI?
MRI is really more for thepatient that is either diagnosed
with breast cancer or has anincreased risk.
(02:39):
Most of the women with averagerisk.
You can stop after theultrasound.
Right, you're done.
You've done everything you needto do.
But as a radiologist, I stillmaintain the ability to decide
what I think that patient needs.
So I may look at a mammogramand I may describe what I would
call a complex parenchymalpattern, and what I mean by that
(03:03):
is that when I look at herbreasts, not only is she dense,
but I see nodules here, nodulesthere, like masses, or I see
lines.
I just see that she's verycomplex and I know that I feel
that that patient really needsto go to MRI next.
So the radiologist alwaysmaintains the ability to be able
(03:25):
to say what needs to be donenext.
Dr. Michael Koren (03:27):
Approximately what percentage of women have
this dense breast phenomenon?
Dr. Sue Jane Grosso-Rivas (03:32):
Well, according to what you know, the
lexicon, meaning the AmericanCollege of Radiology, and
they've done a lot of studiesabout 40% of the population, oh
wow.
So there are four categories.
It's A, B, C, D.
A is completely fatty.
B is what we call scatteredfibroglandular, which is just
(03:53):
25% of this tissue.
Right, that becomes kind ofwhite.
C and D are heterogeneouslydense, which is 75% of the
tissue is there and extremelydense is.
You know, almost all of it iswhite.
So when they look at this, theysay 40% of women have dense
(04:13):
breasts.
They're in the category C or D.
Now I will tell you that certaincommunities have more dense
breasts than other communities.
So if you go to certain partsof the country, right, it could
be body habitus, some women, youknow, when there is some
obesity, right, those women tendto have more fatty breasts.
(04:35):
And when you have women, youknow, maybe in a population
where everybody's exercising,they're on hormonal replacement
therapy, you know, they're verythin, they watch their weight
those women are not going tohave as much fat in their
breasts.
Now, density is determined bygenetics.
You're either dense or you'renot dense.
But it also is affected bywhether you have hormones,
(04:57):
whether you exercise all thetime there's no fat, so on and
so forth.
But it was funny because when Iwent from Staten Island and
came to where I work now, it wascomplete.
I could not believe how manywomen were dense.
So I would say it's not 40%.
In my neighborhood, in mycommunity where I am now, I
would say 60 to 70% of women aredense.
Dr. Michael Koren (05:19):
Really, and that's in New.
Jersey right
Dr. Sue Jane Grosso-Rivas (05:21):
Yeah New Jersey.
When, of course, sometimes youmay have heard New Jersey
supposedly has a higherincidence of breast cancer,
because that's the other thing.
It's like going to differentparts of the country you find
different incidence of breastcancer and the population in New
Jersey is very large; a lot ofbreast imaging centers in New
Jersey.
Dr. Michael Koren (05:42):
And the epidemiology of breast cancer
when I was doing internalmedicine was that if you had
your first child later in life,you're more likely to get breast
cancer.
Is that still considered to beaccurate?
Dr. Sue Jane Grosso-Rivas (05:52):
Yes, they still use that and this
risk assessment that I told youabout.
That's some of the questionsthat they ask.
They will say have you hadchildren?
When did you have your firstchild?
Right, so if you had your childyounger although they say like
less than 20 is is mostprotective, I mean most women
are not going to have it at thattime.
But, um, so what?
(06:13):
Also, when did you have yourmenstruation, your first
menstruation?
It's like the earlier you hadthe menstruation, the more risk.
Uh, when did you have menopause?
The later you have menopause,the more risk.
So those questions are allasked in the risk assessment.
So that's still all part of it,but the single most important
thing is just being a woman andgetting older.
(06:36):
I mean that's why you need toget checked out.
Dr. Michael Koren (06:40):
So this is fascinating.
I'm loving all this information.
Thank you for sharing it.
So there's two more things onmy mind that I want to cover.
One is AI that's what everybodytalks about, and the other one
is men.
We'll make that last, buthopefully not least.
So, lets jump into AI, andcertainly AI is the buzzword,
and it has affected differentareas of medicine.
(07:03):
I like to tell my staff herethat for every incidence of AI I
see an incidence of ASartificial stupidity, and I
don't know if you want tocomment, but we've heard that it
is having a big effect inimaging overall and maybe
particularly breast imaging.
So tell us a little bit aboutwhat's happening with AI.
Dr. Sue Jane Grosso-Rivas (07:22):
Sure, you know, Mike.
What's interesting is I metwith a colleague the other day
and her son happens to be inmedical school right now and
she's a radiologist.
So she thought that radiologywould be a wonderful field for
her son and her son said no, mom, AI is taking over, I'm not
(07:43):
going to go into radiology, Iwon't have a job.
So very interesting for me tohear that that is what they are
possibly hearing right At thatstage of medical school where
it's affecting whether people gointo radiology or not, because
they're so concerned that AI isgoing to take over.
So artificial intelligence,right, what is it doing?
(08:04):
Well, look, is it good.
There's good and there's bad,always right.
So with AI and we had somethingbefore AI we had something
called CAD, which wascomputerized assisted diagnosis,
right, or computerized assisteddetection, and we now have CAD.
We've had CAD for years, years,and what the CAD does is it
(08:27):
helps to point out, for example,where there are calcifications,
because calcifications may bethe sign of early cancer, ductal
carcinoma in situ it's only inthe ducts hasn't invaded.
So, as a radiologist, one ofthe things we look for is
calcifications, but sometimesthey're very tiny, they're very
difficult to see.
So the software will pick upwhere there are calcifications
(08:48):
and it puts a mark around it andit says look here, look here.
And that saves you sometimes,right, because the radiologist
somehow didn't see it because itwas so tiny.
So we've had that for a while,because it also even picks up
masses or distortion.
But now AI is around and thereare quite a few radiology
(09:08):
practices that have it already.
So I just want to talk about thebreast imaging part.
So tomosynthesis right, that'sthe one I told you about that
slices through the breast andthere are several images.
Now one breast could have 80something images.
Like we don't realize.
We went from four images of thebreasts to now having, you know
(09:31):
, 80 images of one breast, 80images of the other breast.
I mean it gets to be almost toomuch all the slices that you
have to look at.
So AI for us, what it does, it'sgot an algorithm that has been
developed over time.
Right, these companies makethem better and better with time
because they feed them withinformation of you know, this is
(09:51):
what a cancer looks like.
You feed them all thisinformation and now this
algorithm comes along, looks atthe images, those 3D images, and
it says here it is, there's acancer right there.
There's a cancer right there.
Look here, look here, look here.
And there have been somestudies that are saying that AI
is picking up some cancers thatthe human eye has not picked up.
(10:14):
Right, we're only human.
Sure, you know we're we couldpossibly not see a subtle
finding.
Do I think AI has replaced theradiologist?
Not yet, not not at this point.
I have AI for one of theoffices and what'll happen is
it'll point to something for me,but ultimately it is the
(10:35):
radiologist that has to look atthose images and evaluate it and
decide is AI being stupid rightnow or is it really something?
And then you decide whetherthat patient has to come back or
not.
So I think we need to learn howto live with AI in our world.
Basically.
Right.
Dr. Michael Koren (10:53):
So we're certainly not at a point where a
radiologist or a group or aprocess that doesn't use AI is
somehow behind the times.
Right, we're not at that point.
Dr. Sue Jane Grosso-Rivas (11:04):
You have to be with the times, for
sure, and you have to learn.
You know, with every newtechnology that comes along and
we haven't even talked aboutcontrast enhanced mammography,
which you probably probablyshould mention, but with every
technology that comes along, youhave to kind of embrace it, you
have to look at it and you haveto see, well, how does this
help me?
You know, how can I use this tomake me a better physician?
(11:27):
What can this do for me?
And that's kind of the way thatI'm looking at it.
I'm towards the end of mycareer, so I'm not worried that
AI is going to replace me.
Dr. Michael Koren (11:35):
I think, based on the way you look,
you're at most halfway through.
Dr. Sue Jane Grosso-Rivas (11:39):
Yeah, Okay, Okay, Mike, let's just
say that that's true.
But I mean, I enjoy what I do,so I'm not going anywhere
anytime soon.
But yeah, no, AI is here andand you know it's.
It's going to be interesting tosee what happens in the future
with AI, because it's also goingto be used for magnetic
resonance imaging.
It's being used in manydifferent areas of radiology at
this point, so it remains to beseen.
Dr. Michael Koren (12:00):
So you mentioned contrast imaging, so
go ahead and give us the quickspiel on that.
Dr. Sue Jane Grosso-Rivas (12:05):
Okay, so we talked about x-rays being
static, but you know, contrastenhanced mammography and MRI
with contrast is not static,it's more functional, it's more
physiologic.
You know, with contrast agents,if you put either iodinated
contrast IV for contrastenhanced mammography, it's the
same IV contrast that they usefor CT scans.
(12:31):
Or if you use a radio tracer,like for positron emission
tomography, all of these typesof studies, the agent goes into
the body and it goes to aparticular place where for
positron emission tomography,it's where they're using glucose
.
With contrast enhancedmammography and magnetic
resonance imaging it's aboutflow.
Cancers develop blood vessels.
(12:52):
That's what cancer does.
Cancer wants to grow, so thevessels are created and it grows
.
And guess what?
The blood flow goes to thatcancer and then it shows up.
So contrast enhancedmammography means I'm doing a
mammogram but I'm giving yousome contrast because I want to
see the flow.
(13:12):
I don't know, I don't want tosee white.
They're subtraction images andit's going to show me where
there is a lot of blood flow.
And where there is a lot ofblood flow is where there's
going to be a cancer, and that'sthe same thing with magnetic
resonance imaging.
Contrast enhanced mammography'sgoing to be a cancer.
And that's the same thing withmagnetic resonance imaging
Contrast enhanced mammography isgoing to take off.
(13:32):
That's one of the newesttechnologies and they have a
study going on right now.
It's called the CMIST trial.
It's basically GE, togetherwith, you know, actually Estee
Lauder company.
I forgot the name of it.
I think it's called BreastCancer Research Group, I think
it's called.
So they've come together andthey are looking to see if women
(13:57):
with dense breasts, withaverage risk, will benefit from
contrast enhanced mammography.
And that comes up and shows usthat it is a good study.
I think we're going to see alot more of that for sure.
Dr. Michael Koren (14:08):
Wow, fascinating.
Dr. Sue Jane Grosso-Riv (14:09):
Because , it's easier.
Contrast-enhanced mammographytakes about anywhere from five
to eight minutes, whereasmagnetic resonance imaging takes
more like 30 minutes 35 minutes.
And MRI is very expensive.
Contrast-enhanced mammographyisn't.
So there are a lot of prosbasically for contrast enhanced
mammography.
But having said that, nothingbeats breast MRI.
(14:32):
Breast MRI is still at the topas far as being able to show
invasive breast cancer.
Abbreviated breast MRI is oneof the newer technologies where
they've learned that they don'thave to do the study for as long
.
They just have to do one or twoimages and they get to see what
they need to see.
So it's much shorter scan time.
Dr. Michael Koren (14:53):
Interesting.
So, last but not least, men andbreast imaging
Dr. Sue Jane Grosso-Rivas (14:57):
oh men, yes, yes, and I do get to
see a few men in my practice.
Dr. Michael Koren (15:01):
The forgotten sex, go for it.
Dr. Sue Jane Grosso-Rivas (15:05):
Yes, well, for the men, only 1% of
all breast cancers are in men,you know, whereas women, the
number of invasive breastcancers that may be shown this
year maybe, you know, greaterthan 300,000,.
Let's say a man, the men willhave breast cancer, maybe 2000,
you know of all the breastcancers.
So it's not common.
It happens as they get older.
(15:27):
So most of the breast cancersyou see in men are over the age
of 60.
Men do not get screeningmammography.
Okay, that hasn't beeninstituted.
The way that men present isthat a man will feel a lump.
When they feel a lump onclinical, or if the doctor feels
a clinical on clinical exam,they feel a lump.
(15:48):
That's when they end up comingto me.
I will do a mammogram on a man.
Okay, they have enough breasttissue to be able to do a
mammogram and we're looking forcancer.
Generally.
The difference, you know, orwhat we're looking for basically
in men, is they feel a lump.
Is the lump cancer or is itsomething benign, like
(16:10):
gynecomastia, which is thedevelopment of breast tissue
which does happen with a lot ofmen as they get older.
Also, many men that haveprostate issues.
They're on certain medicationthat affects the breast tissue,
they start to develop breasttissue, just like women.
Okay, so that's usually whatI'm trying to evaluate.
(16:30):
And you know, sometimes doctorswill send the man for an
ultrasound, but the ultrasoundis not what we need.
We need the mammogram.
You have a lump, you getmammography.
Now what if a man has a geneticmutation?
Because this is the other thing.
People used to think that yourmother's history was the only
history that was important.
That's not true.
(16:51):
Now we want to know your familyhistory on your mother's side
and your father's side, becauseyour father could have the
mutation.
Dr. Michael Koren (17:00):
Yeah, makes sense.
Dr. Sue Jane Grosso-Rivas (17:01):
If the father has the genetic
mutation, then that's going toincrease his risk for breast
cancer, as well as his children.
So, yes, and men don't getscreened, but men do well If
their breast cancer isidentified.
They usually get identifiedearly because men don't have a
lot of breast tissue, so it'svery easy to feel you know the
(17:24):
cancer basically.
So men do tend to do well.
Dr. Michael Koren (17:28):
Yeah, In the cardiology world we use a drug
called spironolactone quite abit that causes gynecomastia and
if we identify that, is that areason to get a mammogram or
just get them off thespironolactone?
Dr. Sue Jane Grosso-Rivas (17:41):
What ends up happening is that they,
you know it doesn't feelcomfortable for a man when they
start, you know, because whathappens is they develop breast
tissue and they'll developtenderness, which is
uncomfortable.
So sometimes what ends up isyou'll have to get them on
something else, some othermedication, basically you know,
Dr. Michael Koren (17:58):
But they don't necessarily need to be
imaged, I guess, is my question.
Dr. Sue Jane Grosso-Rivas (18:06):
He has to be imaged.
Dr. Michael Koren (18:07):
he has to be Okay.
Oh, interesting,
Dr. Sue Jane Grosso-Rivas (18:08):
If you, if you feel a lump and he's
on spironolactone, there's noway to know if the lump is
because of the spirono lactone,with gynecomastia, or is there
cancer.
Dr. Michael Koren (18:13):
Or if there's no lump, just enlargement of
the breast.
Do you still recommend amammogram?
Dr. Sue Jane Grosso-Rivas (18:17):
I would still do imaging.
I would do imaging, yeah.
Dr. Michael Koren (18:20):
Yeah, well, I'm going to be sending you some
referrals then in the nearfuture, all right, that sounds
good.
Dr. Sue Jane Grosso-Rivas (18:25):
So you know
one thing I do want to mention,because you're a cardiologist
what about arterialcalcifications on a mammogram?
Have you heard about that?
Dr. Michael Koren (18:35):
I've heard of them.
I'm not sure exactly what Iwould do, but I do get a lot of
referrals from other imaging tocardiology because of concerns
about coronary calcium.
But go ahead.
I'm sure you see that as well,yeah.
Dr. Sue Jane Grosso-Rivas (18:48):
I mean it's very interesting
because when I look at amammogram and I'm looking for
calcifications, sometimes I seevascular calcifications, so
breast arterial calcifications.
Now, let's say it's a woman,that she's in her 40s and I see
a lot of calcifications in her.
You know vessels.
I do report it.
Not all radiologistsnecessarily report it, but we
(19:08):
all know that there does seem tobe some association with, uh,
having vascular calcificationseen in your breast.
There seems to be someassociation with cardiac disease
and also the potential fordeveloping a stroke.
So you know, as a woman getsolder, you'll see vascular
(19:28):
calcifications more right,because basically she's
developing calcificationseverywhere, which includes the
breast.
So it is something to mentionand maybe it's an opportunity
for the primary care physicianto sort of look at that patient
and start assessing.
You know, how is this person'scardiac health?
Because ultimately we'retalking about breast cancer,
right?
But the leading cause of deathin women is still cardiac
(19:50):
disease right.
Dr. Michael Koren (19:52):
So A lot of women forget that, unfortunately
.
Dr. Sue Jane Grosso-Rivas (19:54):
Yeah, no, it's like, you know, breast
cancer.
And breast cancer is not eventhe leading cause of death.
It's lung cancer still, butbreast cancer is still the
leading cancer.
We should say but so, yeah, soif there are arterial
calcifications of the mammogram,we shouldn't totally ignore
them, because that may help todetermine if she has some
(20:16):
cardiac disease.
Dr. Michael Koren (20:17):
And I'm going to throw my final question out
at you a little bit out of leftfield, but it's something we've
addressed here in MedEvidence.
What are your thoughts aboutalcohol and breast cancer risk?
Dr. Sue Jane Grosso-Rivas (20:37):
Well, I think, like with anything, as
far as risk is concerned theyalways askhow can I , " "Reduce
my risk of breast cancer, right?
So you're going to hear fromany doctor for any cancer, right
?
Lifestyle you know.
Obesity they say with obesitythere's an increased risk.
You know.
You want to eat well, you wantto exercise, you know all of
(20:59):
these things.
But then yet I can tell youabout my very good friend who
was at the age of 40.
She was a runner, right.
She drank, you know, greenjuice or whatever it is she was
doing.
She had cancer, right.
So it doesn't just because youdo all these things doesn't
necessarily protect you.
Alcohol, from what I've heardand actually I was listening to
one of your podcasts, I thinkfrom Med Evidence, and I did
(21:20):
hear you guys talk about alcohol, but everything in moderation
is the way I feel.
I feel to say to someone don'tdrink alcohol at all.
I don't think that makes anysense, Just like, you know,
don't drink coffee, right?
If a patient comes into me,she's got multiple cysts.
(21:40):
We know caffeine can affect thebreasts and they could end up
developing more cysts.
But are you going to tellsomeone, well, you've got to
stop caffeine.
You know completely.
Very hard to do, I think ifsomeone's drinking alcohol on a
daily basis, that's too much andI do think that that is of
concern.
So, yeah, no, I would say.
Dr. Michael Koren (21:57):
All good things in moderation is the
lesson.
Dr. Sue Jane Grosso-Rivas (22:02):
I personally think, all good
things in moderation, but westill don't know exactly what's
causing the breast cancer.
Right, I already told you thatmost of it is not genetic that
we know of, although every year,right, every time, we hear
about more genes, more genes,and I, for example, we haven't
really talked about stories.
I have so many stories ofpatients, but a friend of mine,
(22:23):
his daughter, just passed awayat the age of 34 from metastatic
breast cancer and there'snobody in the family, just
nobody in the family.
So why, you know those, thosecases that I know of where
there's no?
And then I have another personwho's uh, was a technologist of
mine, you know developed DCIS ata young age and no genetics,
(22:45):
nothing.
And then her daughter, at theage of 31, finds her own, feels
her own breast cancer, okay,saves herself, basically.
No genetics! So so what's goingon, so you know, and and we
didn't get into is that we arefinding we didn't talk about
black women and there's a bigproblem that's going on.
(23:06):
And the ACR has now actuallyissued some new recommendations
and this is very important tosay right now which is that all
women should have their riskassessment at the age of 25 to
30.
And what that means is that whenyou go in to see your, you
should go in to see your primarycare physician, because a lot
(23:27):
of women don't know that thereis this genetic predisposition.
We need to know if there isfamily history.
You know how many times I talkto a patient and they don't even
know their history and whenthey find out there's something
abnormal, they go back and starttalking to all their family
members and then they find outoh yes, aunt so-and-so, cousin
so-and-so.
They start finding out all ofthese histories.
(23:49):
Well, that's what the newrecommendation by the American
College of Radiology you got tofind out by the age of 25 to 30.
And why?
Because if there is a geneticpredisposition or significant
family history, that woman mayneed to start earlier than 40 to
get her mammogram.
That woman may need to getbreast MRI, for example.
(24:11):
Right, and what they found isthat something is happening
within the black women, the agesof some of them, because you
can get cancer between the agesof 20 and 29.
It's not common but you can,and what they found was that
black women are getting the 50%more cancers in in black women
from the ages of 20 to 29 thantheir white women counterparts
(24:36):
Right 30 to 39, it's only aboutmaybe 17% increase.
Something is happening and manyof the black women get the more
aggressive type of breastcancer.
It's called triple negative,meaning it's ER negative, pr
negative.
You know, estrogen,progesterone negative and HER2,
herceptin negative.
They are much more aggressivecancers.
(24:56):
So you know, it's almost youknow, a warning that's going out
there to let everybody know.
Hey-
Dr. Michael Koren (25:01):
Any theories as to why that is?
Out of curiosity?
Dr. Sue Jane Grosso-Riv (25:04):
They're looking into the possibility.
They want to look at the typeof cancers, the molecular basis,
but what they have foundoverall not even just black
women, asian women, right, theyhave a lower incidence in
general, but they're findingthat the younger women are
starting to have more, there'smore of an incidence of breast
cancer, and people are trying tofigure it out.
(25:26):
And a lot of these breastcancers are estrogen receptor
positive and progesteronepositive also, so they tend to
be estrogen type tumors, right?
So I don't know, we haven'tfigured out exactly what is
going on.
But then let's go back tolifestyle.
That's what I'm saying.
So what is it?
So, if you ask me about alcohol,you know, is it related to the
(25:50):
way you're living your life,right?
Is it related to the way thatyou're eating?
Is it nutrition?
Is it the environment?
What do we have in ourenvironment?
The microplastics?
I don't know right.
There's got to be.
There's something that'shappening.
The good news is that for thepast 50 years, the mortality
rate for breast cancer hasdropped significantly.
(26:13):
So there is no doubt that weare doing a better job with all
of the screening, mammography,maybe the new chemotherapies
that are out there.
Whatever it is that we're doing, it is much better.
Women are surviving breastcancer.
There's no doubt about it thatthey are.
Whether it's stage zero, stageone, stage two, women can still
(26:34):
survive their breast cancers,absolutely so that's the good
news.
Dr. Michael Koren (26:39):
So, Sue Jane, a lot of people are concerned
about the cost of health care.
Tell us a little bit about whatthe expectation should be of a
woman who needs these screeningprocedures and what her
insurance company should pick upand what the cost should be
approximately.
Dr. Sue Jane Grosso-Rivas (26:54):
Well, you know, at this point,
because all of theseorganizations have agreed that
screening mammography shouldoccur, right, they should be
able.
Their insurance company shouldbe paying for their screening
mammography.
Dr. Michael Koren (27:08):
Zero out of pocket usually?
Dr. Sue Jane Grosso-Riv (27:10):
Usually a zero out of pocket, usually.
Now they may have, however, adeductible that they have to
meet, right?
So I shouldn't say everybody,everyone's insurance is
different.
Let's talk about Medicare, forexample, right, medicare.
Like most women that come fortheir mammograms, many of them
are older, they're Medicare age.
So the woman must know what theMedicare rules are, because you
(27:35):
know if they come just a fewdays too early, you know if it
has to be exactly at 12 monthsthat they can get their
mammogram.
If not, then they will beresponsible for the bill, right?
So they need to be aware.
Some insurance companies willsay you don't have to wait a
whole year, just do it at somepoint in the year.
So it just has to be, you know,this year, next year, it
(27:57):
doesn't matter what month.
Every woman has to be aware.
Now there are screening programsout there.
You know that that will pay forfree mammographies.
And you know in in New Jerseythere's something called the
seed program and that seedprogram will help women get
mammograms for free.
So there are ways of gettingfree mammography.
(28:17):
But as far as insurance isconcerned, yes, you're right,
this is something you need tolook into because if that
insurance company believes thatyou should only get mammography
every two years.
They may not pay for every year, right.
But what about supplementaryscreening?
Your radiologist reads it andsays you need an ultrasound and
(28:37):
your insurance company turnsaround and says, no, you don't,
right, that's a problem.
So you need to know what stateyou live in and you need to know
what the laws are, becausethere are states where the law
does protect you and theinsurance company has to pay for
your supplementary study.
The only way to know is tospeak to your insurance company.
(28:58):
Many women go back and fightwith their insurance companies
if they have to.
Breast MRI is another issue.
Sometimes you hear breast MRI.
Well, we can't get theinsurance company to agree to do
the breast MRI.
So I'm very careful in myreports.
I make sure that I make it veryclear as to why I am
recommending this breast MRI,because that report is going to
(29:18):
help determine whether herinsurance company will pay for
it.
But you're right, you have to.
And how about this?
When should you stop doing amammogram?
And I'm sorry we didn't get totalk about this, but this is
important because manyorganizations will say stop at
74.
I mean 74-year-olds say, 75, Imean nowadays people are living
(29:41):
much longer, right?
So the American College ofRadiology says this, and I
believe this as well you stopwhen you are no longer going to
be in good health.
If you're going to be in goodhealth for the next 10 years,
then you should continue to getyour mammogram.
So if you got a 74-year-old andshe's doing very well and she
(30:05):
expects you know, the doctorfeels like she's probably going
to live until 84, then yeah, sheshould continue getting her
mammogram, right.
So, but what if the insurancecompany doesn't pay for it?
That's a problem.
Dr. Michael Koren (30:18):
Well on that.
I truly want to thank you forthe MedEvidence family for a
true tour de force.
Thank you, Sue Jane, for a truemasterclass on breast imaging.
I learned a tremendous amount.
I'm sure our audience willshare that sentiment quite a bit
.
And thank you for sharing yourstory about Ms.
(30:40):
Goldberg.
And thank you for just atremendous number of very
pragmatic insights that I'm surewill make a difference in
people's lives.
Dr. Sue Jane Grosso-Rivas (30:48):
My pleasure.
My pleasure Any opportunity Ihave to get information out
there.
I just think it's what I'm hereto do.
Announcer (30:56):
Thanks for joining the MedEvidence podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
NFL Daily with Gregg Rosenthal
Gregg Rosenthal and a rotating crew of elite NFL Media co-hosts, including Patrick Claybon, Colleen Wolfe, Steve Wyche, Nick Shook and Jourdan Rodrigue of The Athletic get you caught up daily on all the NFL news and analysis you need to be smarter and funnier than your friends.