Ep. 510 Confused by Mammograms, Breast MRIs & Ultrasounds? – The Clear Guide to Breast Imaging with Dr. Robyn Roth
- Cynthia Thurlow
- 11 minutes ago
- 37 min read
As a nurse practitioner, I feel a deep responsibility to my listeners and community to ensure that every guest I bring on shares accurate, evidence-based information. A few months ago, I decided to remove two podcasts from earlier this year to make way for an expert who could speak specifically and authoritatively on breast cancer health. So, I am honored to welcome Dr. Robin Roth today, better known as The Boobie Docs, on her popular breast health social media platform, where she shares information about breast cancer in a fun and educational way.
Dr. Roth is an associate professor of radiology, specializing in breast and abdominal imaging. She is also the host of The Girlfriend's Guide to Breast Cancer podcast, created to support those navigating a breast cancer diagnosis or caring for a loved one.
In our discussion today, we dive into misinformation about breast health and breast imaging. We explore the importance of acknowledging disinformation on social media, risk factors for early breast cancer screening, significant and modifiable risk factors, and the effects of dense breast tissue. We examine breast imaging, exploring ultrasound and mammography, the differences between 2D and 3D mammograms (the gold standard), and when to use MRIs. We clarify why thermography and QT imaging are not the gold standard, and why we need to request different types of imaging modalities. We discuss the importance of screenings, challenges, including diagnoses like DCIS, personalized approaches to breast cancer screening, breast cancer staging, and issues with imaging after mastectomies and with implant placement. Dr. Roth also explains how 80% of breast biopsies end up being benign, how to manage anxiety and callbacks for mammograms, how to understand lab reports in plain language terms, and the benefits of supportive resources like cancerbesties.com.
With her expertise and approachable style, Dr. Roth reminds us that proper information can make all the difference when it comes to breast health. You will not want to miss this conversation, especially during Breast Cancer Awareness Month.
IN THIS EPISODE, YOU WILL LEARN:
How online platforms fuel confusion around breast health and imaging
Disinformation may influence breast cancer screening decisions
Modifiable factors that can reduce or increase your risk of breast cancer
Why dense breast tissue matters for imaging accuracy
Ultrasounds, 2D and 3D mammograms, and MRIs
Thermography and QT imaging are not gold standards
Why every individual DCIS diagnosis needs a personalized approach
Breast cancer staging and how it guides treatment
80% of biopsies are benign, but still essential
How to manage anxiety around callbacks and make sense of lab reports
“If something looks abnormal, we need to check it — that’s why callbacks happen.”
– Dr. Robyn Roth
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Submit your questions to support@cynthiathurlow.com
Connect with Dr. Robyn Roth
On her website
Social Media: @the boobie docs
Preorder a copy of Everyone Has Boobies
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:27] Listeners, I know that you all know that I take podcasting really seriously and as a nurse practitioner, I feel a tremendous responsibility to my listeners and my community to ensure that the guests I bring on are presenting you all with the best information. And I made a decision a few months ago to pull down two podcasts that were done earlier this year with the intention of bringing on an expert that would be able to speak specifically to breast cancer health.
[00:01:01] So today I have the honor of sharing with you Dr. Robyn Roth's work. She is an Associate Professor of Radiology specializing in breast and abdominal imaging. She's better known as The Boobie Docs, her popular breast health social media platform where she discusses breast cancer in a fun and educational way. She also has a podcast, The Girlfriend's Guide to Breast Cancer, to help those navigating a breast cancer diagnosis or supporting a loved one. I very transparently shared with Dr. Roth why I thought it was so important to bring her work on the podcast and she was incredibly gracious.
[00:01:36] Today, we spoke about misinformation regarding breast health as well as breast imaging, the importance of acknowledging disinformation on social media, risk factors for screening earlier for breast cancer, important modifiable risk factors, the impact of dense breast tissue, breast imaging health specifically looking at ultrasounds, mammography, the differentiators between 2D versus 3D mammograms which are the gold standard, when to use MRIs, why thermography and QT imaging are not the gold standard and why we need to ask for different types of imaging modalities, the importance of screenings, specific challenges including diagnosis like DCIS, personalized approaches to breast cancer screening as well as breast cancer staging, challenges with regard to imaging after mastectomies and with implant placement, how 80% of breast biopsies end up being benign, managing anxiety and callbacks for mammograms and cancerbesties.com and being able to utilize your lab reports to get information in layman specific language. This is an invaluable conversation, one that's incredibly important for Breast Cancer Awareness Month. And Dr. Roth's work is so so important and needed in the space.
Dr. Robin Roth: [00:03:12] Thank you for taking that down and providing your listeners with accurate information and owning up when you make a mistake.
Cynthia Thurlow: [00:03:19] Yeah, yeah, absolutely. And that's actually what I'm going to say is that--
Dr. Robin Roth: [00:03:21]: Yeah.
Cynthia Thurlow: [00:03:22] We've had a couple people that like, we've had to take down because the podcast has been around technically since 2018, but I haven't, like, this was a big deal. Like it was pulling it off of every social media platform. Like there was a clip on TikTok and I was like, “Oh my God, he has to come off.” Because I just can't be part of medical misinformation.
Dr. Robin Roth: [00:03:41] I'm so happy.
Cynthia Thurlow: [00:03:43] I would love to start the conversation, Dr. Roth, talking about common misconceptions around breast health and radiology. I know that have a very paternalistic perspective in traditional medicine, and yet I think that social media in some ways does a great job with helping bring greater awareness to key themes. At the same time, there can be a lot of frankly, medical misinformation. How do you navigate this as a clinician and a fellow middle-aged woman?
Dr. Robin Roth: [00:04:15] Thank you so much. There's so many important things I want to talk about on this podcast, starting with the medical misinformation that's out there. We know that 50% of young people get their health information from social media. And there is dangerous medical misinformation and disinformation being spread. Disinformation is when someone's spreading misinformation for personal gain. And a lot of what we are seeing is just that. So when someone tells you that mammograms cause cancer and DCIS isn't cancer, you could cure it with this diet, they're usually trying to sell you something. They don't have their-- they probably don't have your best interest at heart. And I say that very strongly because I know for a fact.
[00:04:58] You and I both know that there are predatory type of behavior going online, where mammograms cause cancer, but then they're trying to sell you some other shiny new technology that isn't even approved for breast cancer screening, isn't interpreted by the radiologist that it claims to be read by, or these diets haven't been proven to really prevent breast cancer. You could do everything right. You could live a perfectly pristine, healthy diet, never have a toxin in your life, and you can still develop breast cancer. And that is an important message I want your listeners to take home is that there are certainly things that we can do that are in our control to lower our risk of breast cancer such as eating healthy, exercising, limiting alcohol and smoking, moving, all those things.
[00:05:41] But there are still environmental components that are completely out of our control or a lot of times out of our control. There are familial and genetic things that we'll talk about. When we talk about breast cancer, we talk about modifiable and non-modifiable, so the things that you can change are the things that you can't change. There's plenty of things that we could change, but there's lots of things we can't change. And that's why breast cancer screening is so important, because early detection is the best protection. When we find your breast cancer early, you could benefit from the greater than 99% survival rates and just less aggressive treatment and better quality of life after breast cancer. Because chances are you're going to beat the breast cancer, thanks to technology such as the mammogram, better treatments.
[00:06:27] But when there's just so much misinformation going on out there about how breast cancer is even detected and blaming the mammogram on breast cancer-- like blaming breast cancer on the mammogram, it is such a dangerous, dangerous door that we're opening up. And it's scary out there. That's why I'm on social media. I don't want to do this. This is not something like it chose me, because I was so infuriated by the constant misinformation. And I know this is where people are getting their health information, so I just need to be a voice that provides accurate, evidence-based medicine and health information.
Cynthia Thurlow:[00:07:02] Yeah, and I think if someone hears that a screening modality is causing cancer, that's scary, and I can appreciate and understand why people might be fearful. But I think on the same token, it's like this is why your voice is so important in this space to help provide accurate information. And so when we're talking about risk factors, things cannot modify, like for the most part, lifestyle, what are we speaking to? So for listeners, the individuals that are at greater risk of developing certain types of cancers, including breast cancer.
Dr. Robyn Roth: [00:07:40] Right. Well, I want everyone listening to understand that the two greatest risk factors for developing breast cancer are being female and getting older. By definition, we are all at risk. Most people who are diagnosed with breast cancer have no known family history or genetic mutation. So off the bat, everyone has to take breast health seriously because we could all unfortunately develop breast cancer. Our loved ones, we know the number, one in eight, that's only invasive breast cancer. DCIS, which is most certainly early-stage breast cancer, very treatable, but if left untreated, can turn into more invasive breast cancer. That actually is more than one in eight. So statistically speaking, you or someone you love is going to be diagnosed with breast cancer over your lifetime.
[00:08:22] The goal is really to catch it early, so that's my KEIKO message there. [chuckles] But in terms of the things that we have control over, so we can lower-- you want to maintain a healthy weight and exercise at least 30 minutes a day. You would like to control your alcohol, unfortunately, and this brings me much pain to say this, but alcohol is one of the biggest carcinogens known to man. It increases your risk of many cancers, including breast cancer. And like, really, there's no safe amount of alcohol. But I say that with note, with everything in moderation. I love to have a cocktail every now and then. There are some things, my perspective is it I'm going to get breast cancer-- but it's just a matter of when.
[00:09:03] I hate to say that, but I see it every day, day in and day out. It's hard not to believe but that's true. And it's not the drink that you had last night that caused your breast cancer, right? You still have to enjoy life and everything in moderation. But limiting smoking, moving your body, I think the things that are contributing to-- I forgot to add, a plant-forward diet that's rich in leafy green vegetables and fiber. All the things that are good for your health are good for lowering your breast cancer risk. So this is all good for your overall health. Because coronary artery disease is a bigger risk factor than breast cancer. But still, we want to put our best foot forward all the time.
[00:09:45] But you brought up a point which was, how do you know if you're at increased risk for developing breast cancer? That's a great question, because even when we talk about a mammogram, we're not talking about breast cancer screening usually until age 40 but that's like some made up number. It's an arbitrary number that insurance has decided as the tipping point of where women will be diagnosed and where you catch the most of them. So there are plenty of women that will be diagnosed before the age of 40 and really the goal is to find those women before they're diagnosed. So I would encourage all of your listeners to find out their breast cancer risk before age 30, ideally at age 25. And ideally this would be done with your healthcare provider.
[00:10:25] But there are easy calculators that you could do, such as the Tyrer-Cuzick model, which has its flaws, but there are a number out there. But if you're greater than 20% lifetime risk of breast cancer, then we would want to start breast cancer screening earlier and more often. So we would start-- So if you have a greater than 20% lifetime risk of breast cancer, we would start an MRI beginning at age 25-- as early as age 25 and a mammogram as early as age 30 kind of alternating every six months, and the goal is really just that early detection. If you're that high of risk, it's more of a personalized approach, trying to find your breast cancer early. So you're never going more than six months without imaging. So for some people, 40 is way too late, which is why it's really important that everyone understand their breast cancer risk score, so if you need to start earlier.
Cynthia Thurlow: [00:11:11] Yeah, it's interesting. I just had my annual GYN exam, and every year I have to take this test before I show up in the office. And I think that for a lot of people it may seem like, “Oh, they're making me sit on my phone for 10 minutes and fill out information.” But it's really to help with the screening process, to help identify people that may be at greater risk for breast cancer, colorectal cancer. And the purpose of screening is to be able to differentiate individuals, like as an example, people with dense breasts. That's a whole separate concern. I know years and years ago, when I was in my 20s and I was in training, I had very fibrocystic breasts and I was at a big teaching hospital. And I recall I had to have an ultrasound, like with some regularity. And they kept saying, you're the perfect example of someone who should breastfeed. If you breastfeed, this would be less problematic. But that is very different than speaking to dense breasts and so help listeners understand what is significant about dense breast tissue that can help obscure the screening process.
Dr. Robyn Roth: [00:12:15] Absolutely. So about 50% of women have dense breast tissue. And the breast is-- what dense breast tissue means, so the breast is composed of fat and fibroglandular tissue and duct, but the glandular tissue is the tissue that appears white on a mammogram. It's also really the hormonally active tissue that honestly is probably more likely to develop breast cancer. So it's a double-edged sword because dense breast tissue makes it harder to find small breast cancers using a mammogram alone. Breast cancer is white and so dense breast tissues, so I liken it to finding a snowflake in a blizzard. The more snow you have, the harder it is to find a single snowflake. But additionally, it increases your risk for developing breast cancer.
[00:12:58] That’s newer knowledge, but like I said, that's where the active tissue is, that's where you're going to develop the breast cancer. So if you have extremely dense breast tissue, it's like as much as four times higher than someone with fatty breast tissue. There's nothing you could really do to change your breast density, a lot of it is genetic. People do tend to get fatty over time. But I have plenty of 80-year-old women that still come in and they have dense breast tissue. But if you have dense breast tissue, because we know it makes it harder to find small breast cancers and we know it increases your risk. I like to tell people to consider adding a supplemental ultrasound or an MRI depending on your risk factors.
[00:13:34] And that allows us to find smaller breast cancers at a more treatable stage. But the downside of supplemental imaging is more anxiety surrounding the test and also more false positives. So, meaning that we might find something that may or may not be breast cancer we might not be able to tell and then we have to do a biopsy. But if you've ever had a breast imaging biopsy done by a radiologist, they tend to be fairly-- I don't want to speak for everybody, I know I've heard horror stories, but for the most part they tend to be minimally painful. We use minimally invasive, so we use numbing medicine to numb the tissue, we take as little tissue as we need to get the diagnosis. And then you leave with a band-aid and you get results three to five days later.
[00:14:19] But for some people that does cause extra anxiety. Supplemental screening is not for everybody, but it's something to consider if you have dense breast tissue. And you would find out if you have dense breast tissue from a mammogram. A mammogram will tell you the ratio of fat to fibroglandular tissue. Other things will tell that too. Like I have no problem with ultrasound telling you, but we really can see it better on a mammogram. And where we're going with-- in terms of mammograms, AI is really going to shift how we screen people in the future.
[00:14:50] We've been using AI in breast radiology for years, but now when we talk about risk models, those are all based on your family history, do you know? But we know just the internal makeup of the breast is actually an important factor too. So the newer types of AI that's coming down the road for mammograms is that it will be able to look at your breasts, take a picture of your breast and tell you to the cellular level what your risk of developing breast cancer is over the next one, five, ten years. So we know if it's safe to screen you every two years or if you're the type of person that may need to be screened every six months, kind of alternating. So it's going to be definitely more of a personalized approach. And I'm very excited for that. I know many people are.
Cynthia Thurlow: [00:15:33] Well, that was one of my questions. So that was very serendipitous that you answered that before I even asked because I think that one of the challenges for people, like, I'll just say perimenopausal women, menopausal women, depending on the screening guidelines, and there's differing opinions on when to start screening for regular non-dense breast tissue, that's number one. And then looking at all these different modalities, like as an example, you know, 2D versus DBT, which is this digital breast tomosynthesis, which I'm probably for the life of me not saying properly.
Dr. Robyn Roth: [00:16:09] You did pretty good.
Cynthia Thurlow: [00:15:33] So for the average person that is getting a mammogram, should they be asking for this DBT? Is that important? As a breast specialist, do you feel like that should be the gold standard for all of us?
Dr. Robyn Roth: [00:16:22] I do, I do. So DBT or tomosynthesis is 3D mammography. And so when we used to take mammograms, there's just a 2D picture of the breast. Now a 3D mammogram lets us scroll through the breast and look at individual slices. So you're able to really pick up things like subtle architectural distortion better. It's also when we used to do-- in the beginning of 3D, we were doing a 2D and a 3D and that was double the dose, but it was still under the MQSA guidelines that are federally regulated that a mammogram has to be lower than 3 mSv per view. But now we got rid of the 2D completely. Now most institutions are using 3D mammography alone, and they're making a reconstructed 2D. So that would be my best advice for everybody. 3D mammography is definitely something you want. I think all people could benefit from it. But certainly, if you have dense breast tissue, you would like that level. So that's the bare minimum of the mammogram that you want for an average risk person.
Cynthia Thurlow: [00:17:22] And that's helpful. I mean, that's something that my local breast cancer screening, that's what they offer. And so I was curious. We go from mammography in younger women. I know sometimes they use ultrasound. So, like, from big picture, when you-- as a breast specialist, when do you feel like ultrasound is particularly helpful?
Dr. Robyn Roth: [00:17:42] Okay, so let's talk about that. So if you have a woman that's under 30 years old, we usually start with an ultrasound. So if you have a palpable lump, you're 20 years old, obviously you want to get a physical exam by your practitioner, but a lot of times they can't tell for certain what it is. And I want to use this point to say, like, if you say it's just a cyst, how do you know it's okay to advocate for that? Maybe an ultrasound. There's really no risk in an ultrasound. It has no radiation. It allows us to tell if something is cystic or solid. A lot of times we're able to tell, no, that's just a cyst.
[00:18:13] Sometimes we need biopsy to prove that it's just a fibroadenoma because breast cancer is it's not that frequent under the age of 30, but it's happening and it's increasing. So we would start with an ultrasound under age 30. Now, if you're 30 and above and you come in with a palpable area of concern, then we would start with a mammogram followed by an ultrasound. A mammogram, big picture, allows to detect the microcalcifications that can be associated with early forms of cancer, including DCIS and invasive ductal cancer. Sometimes it presents as calcifications. A mammography also allows us to look for subtle areas of architectural distortion that I talked about. And it really just helps us big picture look at the breast in a big picture view.
[00:19:00] The dose of a mammogram-- I want to talk about this before I forget. The dose of a mammogram is incredibly low. Like I said, there's some federally regulated numbers that we have to be below. It's under 3 mSv per view. The dose of a mammogram is equivalent to flying cross country about, like, just so that you can conceptualize what that means. Of course, it's localized to the breast. But this is hopefully a once, maybe twice a year type of thing. It allows us to find breast cancer at the earliest, most treatable stage. To say that radiation from a mammogram causes breast cancer is such a gross overexaggeration. I can't-- it's like if you own a gun, I can't even conceptualize how exaggerated that is. But it's a sales tactic for someone who is trying to sell something else. So ultrasound, that's why we use mammogram and ultrasound.
Cynthia Thurlow: [00:19:52] And then so MRI is reserved for, I would assume, looking a little more closely, following a little more closely, obviously an MRI is, depending on the type of MRI you might be getting contrast or non-contrast. So walk us through the MRI process.
[00:20:08] Yeah. So, an MRI is really that we're looking at breast cancer screening for a general population. So you can't walk in and say, I'm going to give someone a $500 test. Every single person in this country is going to get a $500 test to see if they have breast cancer. Because we have a $30 test that could tell us they have breast cancer. So that's why for screening the general population, we start with a mammogram. It is a way that we could-- and again, mammography picks up things that even ultrasound and MRI cannot. It can detect the microcalcification. So that is why I really do feel like mammography will play a role in breast cancer detection until I see some really breast CT, I have questions about. I get asked a lot about that.
[00:20:51] I don't really understand the utility other than no compression. But like, I don't know, I've got some concerns about that as well. So until I find like-- the beautiful mammogram or mammogram alternative that can find all the things that a mammogram can, I think it's going to play a role. That's why it's the gold standard for breast cancer screening. An MRI is certainly a great thing to add. It's expensive. But there are-- if you have greater than 20% lifetime risk of breast cancer, it should be covered by your insurance. So that's why it's important to have it documented, so that way it could cover that. There are also places that will offer more like abbreviated MRIs, which is not the full MRI. It's quicker, cheaper.
[00:21:34] So if you have dense breast tissue but you don't technically qualify for a mammogram, but you want more than an ultrasound, abbreviated MRI might be for you. It's used to screen the high-risk population usually, which is genetic mutation, personal risk of breast cancer and dense breast tissue, greater than 20% using the calculator. And it's also used more in the diagnostic setting. So let's say you have a mammogram and ultrasound that are negative, but you have something suspicious on palpation, then an MRI might be warranted. Or in the case of newly diagnosed breast cancer and you're trying to decide if it's in more than one area of the breast or in the other breast as well, so for staging purposes and then on top of that for-- to assess response to therapy.
[00:22:18] So if you have chemotherapy to make sure that the tumor is shrinking, it's a great way to monitor that. So that's how we use the three types of imaging at the moment. The thing I'm most excited about is contrast mammography, which I use in clinical practice. It's like a mammogram and an MRI had a baby. It has all the benefits, the calcification detection like a mammogram, but it has the contrast material. It's a different kind of contrast material. So CT-- then a contrast mammography uses iodine-based contrast, like a CT scan. MRI uses gadolinium-based contrast, which is a heavy metal. Some people don't like that and too much of that is not good for you either. So all these things have to weigh in risk and benefit.
[00:23:00] Contrast mammography is a lot quicker, cheaper, accessible. It takes a lot less time. I would love to see it being used for breast cancer screening in intermediate and high-risk women with dense breast tissue. I hope that's where we're going.
Cynthia Thurlow: [00:23:14] Yeah, and I love that you review all of these types of testing modalities so you are able to see the pros, the cons, the limitations of one over another. I think it goes without saying that there's a lot of confusion in the health and wellness space. And there are certainly, like, questions that came up. Is thermography beneficial from your perspective, is QT imaging helpful? And certainly as a radiologist, I think it's most helpful to hear this from you because you are the diagnostician. Help us understand, are these helpful? Can they be harmful? What do-- the buyer beware, is what I think is really important to understand.
Dr. Robyn Roth: [00:23:56] Where do I start? [chuckles] Well, let me just start by saying this. So, as a radiologist, a breast radiologist, I am an impartial doctor, okay? I don't get paid every time you get a mammogram. I don't get paid-- I just read whatever they-- whatever this breast cancer screening of choice is that I know to be the most effective. That's what hospital systems are using. When there's data to prove something else, we'll add it to the repertoire. I'd be open to all of this if I felt like it had a role in breast cancer screening. And I can most definitely tell you it does not at this point. So thermography is-- I don't want to offend people when I say this, so I have to be careful. But thermography, it's to detect inflammation in the body.
[00:24:37] It's very nonspecific. And I see a lot of patients that come in after having not gotten the mammogram for a while because they had a normal thermogram and they have breast cancers. So I could tell you for a fact it does not work. And if there's anything wrong in the thermogram, and the same goes for a QT imaging scan. They are going to send you in for a mammogram and an ultrasound even after having told you that this will cause your cancer, they're going to send you for one when real answers are needed. And that's what I see over and over again. I see people coming in with a bogus QT imaging report asking, what does this mean? And I have no idea. They're reporting it in velocities.
[00:25:16] And the most infuriating thing is that people are paying out of pocket for these tests. They think will give them answers and provide them some reassurance. And it's just the opposite. It is a false sense of reassurance. And it is dangerous because you are now relying on somebody who's making money every time that you get a thermogram or that you get a QT imaging scan, and now you're trusting them to find your breast cancer. And meanwhile, a lot of-- these studies are not interpreted by board certified radiologists. So in order to be a radiologist-- a board-certified breast radiologist, I had to do four years med school, six years of residency, one year fellowship and breast imaging fellowship. I have to do 960 mammograms a year.
[00:26:03] I have all these, you know, cute UI things that I have to constantly do to maintain accreditation. You're not getting that when you get a thermogram in some guy's office on the corner. So just buyer beware. Like, look at the credentials of the person that is trying to convince you to get this imaging test. See if they have any financial conflict of interest, which I almost guarantee that they do. And look at other information that they're putting out into the world. Like, if it's in line with they're selling a million parasite cleanses and use this to prevent radiation when you fly in a plane. It's such deceptive marketing. And it can be really-- well, it's really shocking when we hear it, but we're also, like, intrigued.
[00:26:51] But it so is this level of mistrust in the doctors that probably have your back, unless you have reason to believe otherwise. But most doctors out there that credible sources are, they have your best interest at heart. When they start having financial interests dependent on the tech that they're selling, it makes you-- it should make you question everything honestly. And I think you really have to be very careful online about what information you're getting, where you're getting it from, and what they're trying to sell you.
Cynthia Thurlow: [00:27:19] And I think that's why these conversations are so important because obviously I understand and appreciate there are people that will say, I don't want to take hormone replacement therapy in menopause and that's a choice. But I think everyone needs to understand with choices come risks. And certainly, when we're talking about a screening test, we want to use the gold standard. Like, that is what we want to endeavor to do. And one thing that I learned prepping for this podcast is that in another podcast you had mentioned there's limitations to QT imaging. And I want to make sure that we put this on the record. It doesn't detect microcalcifications.
[00:27:56] And so hopefully we can reinforce what that is, which can be an early sign of breast cancer, in particular DCIS, and then the other thing is it doesn't give enough information about tissue up to the clavicle or the armpit, the axilla. And so I think that if anyone's listening and trying to get clarification, we're just not getting enough information. And to your point, you spent 10 plus years training to get where you are.
Dr. Robyn Roth: [00:28:22] And 11 years in practice and I see it. QT imaging is just a fancy ultrasound. It's not approved. It's not FDA approved to replace a mammogram, even though it's kind of being sold as such. Where I think it could have a role is in supplemental breast imaging maybe, but like that's where we're using ultrasound right now. So maybe a 3D could help. But also, like, the way I've seen it marketed also is, like, knowing your breast density composition. So maybe that's where-- If you really wanted to know, how much fibroglandular tissue do I actually have? Sure. Like, if that's worth $600 out of pocket to you, go get it. But I think you have to understand what you're buying into. And you said everything is about making a decision. I want you to make an educated decision, and you owe it to yourself to, like, look up. Does this person have a conflict of interest? Does this make sense? Does this go against everything my doctors are telling me and my [crosstalk] gut is telling me?
Cynthia Thurlow: [00:29:19] Absolutely. And let's talk about DCIS, because I think that it's helpful for people to understand that there are specific kind of challenges but it's also helpful to understand, like, what is the likelihood that this particular diagnosis can go on to develop into breast cancer. And I think that there has been some information, not shared by yourself, but shared across social media, that DCIS is not breast cancer and therefore you don't need to have treatment. And everything I have read has certainly suggested otherwise. So let's talk about DCIS. And again, going back to things that put us at higher risk for going on to develop breast cancer.
Dr. Robyn Roth: [00:30:01] Yeah. So I think we've all kind of seen misinformation spread about DCIS that it is not breast cancer. And I could say with my whole heart that DCIS is most certainly grade zero ductal carcinoma in situ, meaning it hasn't escaped the ducts yet. And if it did nothing, then maybe it wouldn't be a problem. But the problem is that-- so DCIS is when we do a biopsy and we get DCIS. Often, I wish I had the numbers written down. I have it in a post of mine, but it was something like greater than 25% of people will have an upgrade to invasive cancer at the time of surgery. So if you don't go to surgery, you may not know that you ever have invasive cancer. Also, DCIS is not created equal.
[00:30:50] So low-grade DCIS chore, like it may be reasonable to watch and wait with some DCIS, low grade, early. But if you're young and you have high-grade DCIS and you have things that suggest that there may be something else going on, I would treat it like breast cancer. Whether that looks like surgery view, whatever surgery that is or even a surgical biopsy. Let's say you were like, okay, let's just take out the area that had the DCIS and see if there's any invasive cancer or other things that might indicate that this is more than just DCIS. Because when we do a biopsy, it's just that, it's just a sample, a small sample of an area. So it's not always representative. Like sometimes people have like 5 cm of calcification.
[00:31:39] And when it's a large area, I like to do two areas because I like to biopsy the front and the back. Because there might be DCIS over here, but it might be invasive cancer over here. So these are the things that we have to look at and a mammogram will tell us how big it is, the extent, and if this is something that you might be comfortable watching and waiting, right? You always have the decision to not treat. But it is a breast cancer. It is whether or not it's a type that's going to do nothing and stay in your ducts for years and you'll die with it, and I hope that's the case. But there are plenty of women that will fall into this high grade, bordering invasive. I've seen DCIS spread.
[00:32:18] I don't understand how, I can’t explain it, but it happens. So DCIS is most certainly breast cancer. It is the decision whether or not you treat it. I don't think when people talk about DCIS as an over diagnosis, I would say it's not an over diagnosis. It's actually-- it could be an over treatment in some cases. And that is the important thing to know, is that it's all an individualized approach. They might treat you with surgery, they might want to treat you with radiation, you always have the option to not do it.
[00:32:45] I was just on this common panel this morning with two women next to me. Okay, so, one of the women is 32 and she was diagnosed with DCIS. It was invasive at the time of surgery. She is now on chemo. She is going through it, but number one, hers was upgraded. And then the other girl that was sitting to the left of me, she was 36, she felt a lump. It was DCIS. She got a mastectomy, but she didn't do radiation. And three years later, she gets a recurrence, and it's invasive cancer at this point. So a number of people are upgraded, and then a number of people will turn into invasive cancer if left untreated and may even develop another one down the road. So DCIS is really an individualized approach. That's where the future of breast cancer treatment is going to go. It's not going to be a one size fits all approach.
[00:33:35] We do that now, but it's like knowing which one-- we don't know which one of the DCIS are going to turn into invasive cancer entirely or the ones that are going to stay stagnant. So until we do we kind of treat them with-- maybe surgery, maybe radiation, maybe chemo if an invasive cancer is found. But it really is an individualized approach. And that's why, yeah, DCIS is definitely breast cancer. If it's aggressive-- if it’s invasive that's a more personalized thing. But I got brought down by the DCIS is not cancer group. They reported me to the medical board for combating. They reported me to my hospital-
Cynthia Thurlow: [00:34:12] Oh, my gosh.
Dr. Robyn Roth: [00:34:13] -over a video I made that was really combating. I think you shared the video this morning saying that DCIS is not cancer when that is so dangerous. And I have a number of people from that group specifically that have come to my side, like they broke free of the brainwashing of that group. And they're like-- they showed me screenshots of what these women are saying. They have 9 cm of disease and they're still telling them, just watch it. And why is it growing a mass? They want to do another biopsy. Oh, don't do it. And it is just backwards out there. And it's scary because you just need to know where your information is coming from.
Cynthia Thurlow: [00:34:54] Well, and I think, again, transparently, this is a theme that will be shared throughout this podcast. Know better, do better. That was the impetus. Like, it was an immediate decision that this other podcast that had been done had to be removed, taken off of social media. Because I don't ever want this podcast to be a platform for sharing information that may harm listeners. And like I shared with you, my cousin's a physician. She called me immediately, and she said, I'm genuinely concerned about this podcast episode, because I think what people may hear is that they don't need to get screened or they don't need to follow up. And we never want that to be the case. I want women to feel informed and empowered, but I don't want them to not take action out of fear.
Dr. Robyn Roth: [00:35:40] Absolutely.
Cynthia Thurlow: [00:35:40] That's definitely not where we want it to come from.
Dr. Robyn Roth: [00:35:44] And I applaud you for taking the steps to make it right. Because sometimes what infuriates me is I see people spreading these lies on big podcasts, and they have millions of listeners, and all it takes is one person to get in the wrong hands, and then they start sharing with their friends. I get asked about it constantly, did you see this? Yeah, I saw all of it. Like, it keeps me up at night. [chuckles]
Cynthia Thurlow: [00:36:05] I'll be the first person to say I'm a clinician through and through and that is why I take the podcast very seriously. I take my guests very seriously. It's why I'm super conscientious. And if I did something that needs to be rectified, I will do it. And so that is what happened. You mentioned this personalized approach. Kind of walk us through how we stage breast cancers. I think this is really interesting, starting, like, where it starts, which is the type. Kind of walk us through how this works and then what happens if it's no longer localized to the breast?
Dr. Robyn Roth: [00:36:43] Okay, so all breast cancer starts in the breast. Whether it starts in the ducts or the lobules, that is an important factor. So breast cancer is not one disease. It's actually hundreds of diseases that are really differentiated by the size of the tumor, whether there's lymph nodes that are involved, the receptors that the tumor has, whether it has hormone receptors, so estrogen and progesterone positive, or if it has growth factors, such as HER2/neu and based-- so when we do a biopsy, even if we know it's breast cancer, we've still got to do a biopsy because we need to know exactly what type, what subtype it is, the hormone receptors, the grade, the stage, things like that.
[00:37:22] So just because your great-aunt had breast cancer and she had this treatment 40 years ago doesn't mean that you are going to have it. And in fact, I can almost guarantee it's very different than it was 40 years ago. So it's very much this individualized approach to treatment. And it also takes into account your age and things like that. Because if you're—young people are more likely to get triple negative breast cancer. That tends to act aggressively. And there are certain medications that might work well on that one that may not work on the hormone positive one. So that will really decide-- and breast cancer is a very multidisciplinary approach to treatment.
[00:37:57] There is usually a breast surgeon, whether that looks like it’s a mastectomy or a lumpectomy, there may or may not be a radiation oncologist who would do radiation if that's warranted. Often when somebody gets a lumpectomy-- if they want to have a lumpectomy, often they will add radiation on top of it because it lowers-- it’s equivalent to a mastectomy or similar outcomes of recurrence. So you may or may not have chemotherapy and you may or may not have it before or after your surgery. Sometimes if a patient has a large tumor with lymph node metastases, then certainly they're going to want to treat it with chemotherapy or hormone therapy first to shrink it, and then you'll have a better outcome with your surgery. So all of this really goes into how breast cancer is treated.
[00:38:43] And that's why it's so important to have a good team of you-- we talked about an oncologist, a plastic surgeon if reconstruction is for you, a pathologist who's really going to tell if this is DCIS or invasive cancer. It's actually a spectrum, so it's kind of like once you hit the tipping point, it's actually could be invasive. There are other people, like even physical therapists and geneticists, they might come into play as well. So there's all these people that make up the breast cancer team and that's why it's not one doctor. I always say, like, the surgeon kind of leads the ship, but they decide if they need to have an oncologist there by their side as well.
Cynthia Thurlow: [00:39:21] Well, it's helpful to know that there's many differing specialties. There's many people involved with the process for someone that's been a breast cancer survivor and plus or minus fat grafting, plus or minus implants. As a breast imaging specialist, do implants make it harder for you to examine the breast itself?
Dr. Robyn Roth: [00:39:47] No. So if you had a mastectomy and you have an implant, what's interesting is that we don't routinely screen you with imaging. And I think that makes a lot of patients pretty uncomfortable because they just got diagnosed with breast cancer, they take off the breast. You never take off 100% of the breast tissue. There's always some residual. How much residual really depends on the surgeon. And I do think it's a good question to ask because every so often I'll see somebody who has a lot of tissue and I'm like, they're walking around thinking they had a mastectomy when really there is a lot of tissue. So I do think that's something we need to talk about more. And I think it's a question you could probably ask your breast surgeon like how much residual tissue is there?
[00:40:23] But if you have an implant by itself, it doesn't cause you to-- it doesn't make it harder to see breast cancer. It obscures some tissue. But we do extra mammogram pictures called implant displaced pictures. So move that out of the way. We may add a breast MRI in addition, if you have a silicone implant, to determine whether it's intact. Whenever someone gets a breast MRI for implants, I always tell them ask for contrast so that we can exclude breast cancer. Because if it's just a silicone MRI without contrast, you can't really detect for breast cancer. If they're going to do it, you might as well do it.
[00:40:56] So, and if you were dense before, you're definitely going to be dense after, because I feel like sometimes the breast tissue gets mushed together, so it looks more like clustered rather than when it was small. But it doesn't necessarily increase your risk of developing breast cancer or it doesn’t make it harder to find small breast cancers. Some textured implants have been associated with a small risk of implant associated lymphoma and also even squamous cell carcinoma. But they're very small. Those have been recalled. So now the ones that are on the market should be safe for use.
Cynthia Thurlow: [00:41:28] Yeah, that was a question that we got multiple times. So it's very reassuring to know that that is not problematic. Back to biopsies, because I know that you do these in clinical practice?
Dr. Robyn Roth: [00:41:38] Yeah.
Cynthia Thurlow: [00:41:38] My understanding is most technically end up being benign, but then there's this gray zone along with about 20% that are actually cancer. How do you kind of walk us through what that process is like? Because obviously you're doing the biopsy and then you're getting the information to review with the patient before next steps.
Dr. Robyn Roth: [00:41:59] When we create 20% of the biopsies we do, 80% of the biopsies we do are benign. I think that really counts. That only applies if you have a BI-RADS 4, something that's suspicious, because if you have a BI-RADS 5, which is highly suspicious, that means the radiologist is telling you there's a greater than 95% chance that this is cancer. If it comes back benign, I don't buy it. I'm taking it out. I'm going to recommend taking it out. So if you have a BI-RADS 5, the radiologist in no other words, fortunately telling you, you have breast cancer. We're going to find out what it is and we're going to get you the right treatment. But in terms of the BI-RADS 4, 80% of the biopsies we do are benign.
[00:42:39] There are lots of masses that can mimic breast cancer. Meaning when you have a 25-year-old with a round circumscribed mass, sure it's most likely a fibroadenoma and it probably is. And it may be reasonable to follow it depending on how long she's felt it. Is it truly a new mass? Because if it's a new mass, I think it really warrants attention. And that's when I tend to biopsy things. Have you never felt or did this just pop up overnight? But you know that. Then we have to take those more seriously. So if someone comes in with a round circumscribed looking mass, I may say let's just biopsy to make sure that it's not a triple negative breast cancer because triple negative breast cancer looks like a round ball too.
[00:43:18] And sometimes if they say it's been there for a while, it's unchanged, then I might feel comfortable following them in six months, giving them something called a BI-RADS 3, which is when we say there's less than 2% chance of this being cancer. We essentially follow it for two years, prove that it's not doing anything, and then we have left it after two years. But when there's this mass that's on the cusp-- and a biopsy and a breast imaging-guided biopsy is really minimally invasive. I think we talked about this, but I don't want to minimize the whole experience because I know it's very traumatic for some people. I've heard horror stories, but I would say for the most part, people—
[00:43:56] Well, the way we do a biopsy is we find it under imaging, whether that's ultrasound or mammogram or MRI, however we see it best. Ultrasound, I think, is the easiest because-- but a lot of times if it's calcifications, we can only see it on mammograms. We have to do a stereotactic biopsy or if it was found on a breast MRI, then we have to do an MRI biopsy, which is another thing to consider before you get an MRI. So we'll do it however we see best. And then once we find the area, we basically give you numbing medicine through the skin. We give lidocaine to the skin and the deeper tissues. Then we take a biopsy needle, which I usually don't let people see.
Cynthia Thurlow: [00:44:31] I was going to say that’s not something you want to see as a patient, I would [unintelligible 00:44:33], head.
Dr. Robyn Roth: [00:44:34] I say, I'll show you afterwards if you really want to see it. But I let them hear it because it can be startling. For some patients, it usually makes like a clicking noise or like a vacuum noise. So I always try to prepare patients for that because it can make you jump and--
Cynthia Thurlow: [00:44:48] Yes.
Dr. Robyn Roth: [00:44:49] And then we take a few samples, we always put in a biopsy clip. And this is up for debate, but I will have the debate with a patient, but if there's no residual mass, like if it was the tiniest area and I do a biopsy, I really am going to push for that biopsy clip, because if it came back as breast cancer and we don't know where it was, like we lost our target, then you're really kind of locking yourself into a mastectomy or something. I don't know how else you would find it. So that's the purpose of the biopsy clip.
[00:45:17] If there's a large residual mass and we could find it afterwards, if it came back as breast cancer, and you're not going to get some kind of treatment that will shrink it in the interim, then maybe we could have the discussion. But I do think it does cause problems sometimes when patients decline a biopsy clip. And then we kind of need to do it backwards and find it.
Cynthia Thurlow: [00:45:37] It’s like trying to find a needle in a haystack, I would imagine.
Dr. Robyn Roth: [00:45:38] Truly, truly.
Cynthia Thurlow: [00:45:40] How do you manage the anxiety that I'm sure most, if not all patients are experiencing when they're called back? Like, I think one time I had to have a second mammogram. And I remember I brought a good friend with me because my husband was traveling. And I just recall that I would imagine for most people it's so stressful and I would imagine you're incredibly kind and incredibly compassionate as are your team members.
Dr. Robyn Roth: [00:46:06] Yeah, it's a lot. And I find myself in such a unique position because I see women in the waiting room. I sympathize with them. I've been that woman before. But here's what I would say to that woman in the waiting room-- 100 women get a mammogram, 10 of them will be called back, 90 of them will be told everything was normal. So only 10% of women are called back. It sounds like a lot, but really when you're looking at the grand scheme, you know, there's breast cancer in there and we're trying to find it at the earliest stage. So 10 women get called back from this mammogram. Of the 10 women that get called back, six of them will be told everything is normal. It was just overlapping tissue. It was a cyst. We could definitively say that.
[00:46:48] Two of them will be told that it's probably benign-- that's less than 2% chance of it being cancer. We typically follow at 6-month intervals. Another 2 of them will need a biopsy of the 10 women. So 2 out of 100 women need a biopsy. Of those biopsies, like we said, 80% of them will be benign, 20% will be malignant. But that does not apply here at BI-RADS 5. So the odds are in your favor. And I always say the earlier we can find your breast cancer, the better. So it's probably not breast cancer, but if it is, today is the best day to catch it because tomorrow it might be a little bigger and next week it will be bigger. So there's no better time than now to get something checked out.
Cynthia Thurlow: [00:47:27] I think that's really reassuring to hear the statistics broken down in that manner. There was a resource that you mentioned on social media called Cancer Besties. So for people that are looking to simplify their lab reports, and I actually got online and looked at it last night and I thought what a great resource that's available to patients. It seems to be free, easy to access. Let's talk about that. Because there might be people who are just looking to better understand their report. Because if you're not in the medical system, and heck, even if you're in the medical system as a clinician--
Dr. Robyn Roth: [00:48:01] Yeah.
Cynthia Thurlow: [00:48:02] Sometimes there's terms used that you're like, what does that mean? What do I need to be concerned about?
Dr. Robyn Roth: [00:48:08] So cancerbesties.com, I'm not exactly sure that's the website, but Google Cancer Besties. Shout out to my amazing friends Missy and Ann who developed this. They're breast cancer survivors [unintelligible 00:48:18]. They created this app that you basically can upload your imaging report or your test results and it will break it down into plain English. So it will explain what that means in layman's terms. It will also give you follow up questions to ask your doctor. So, what does ER positive mean and things like that and how does this affect my treatment? So, it really is your cancer bestie. Like everyone should be using it. It is such a great website. Glad, we found that resource.
Cynthia Thurlow: [00:48:49] Yeah, no, I love those kinds of resources. And if you were going to leave listeners with one best health tip for their breasts, what would that be today?
Dr. Robyn Roth: [00:48:59] I think that breast cancer awareness and action need to happen all year round, not just during October. And if you have a breast then you are at risk for breast cancer unfortunately. So do your monthly self-breast examination, stay up to date on your breast cancer screening, and see if you qualify for high-risk screening. And be careful out there because the Internet can be a very dangerous and confusing place, especially in the breast cancer sphere.
Cynthia Thurlow: [00:49:23] Absolutely. I can't thank you enough again for your time today and for listeners, Dr. Roth literally drove all the way back to her house to do this podcast and has to go back into the city. So I'm so very very grateful for your time today. Thank you so much.
Dr. Robyn Roth: [00:49:37] Thank you so much for having me.
Cynthia Thurlow: [00:49:39] Yeah. Please let listeners know how to find you. You have such great information. Last night as I was preparing for a conversation, it just made the podcast prep process so much easier because you have amazing content.
Dr. Robyn Roth: [00:49:52] Thank you so much. And so, I'm really excited to launch my new website which is theboobiedocs.com and there you'll find all my social, which is-- I'm really so active on social media. Like if you follow me, @theboobiedocs across all platforms. That's where I provide the day-to-day videos and showing cool things like this that I get to do. And my website will have-- I'm excited to announce that I'm releasing a children's book in January.
Cynthia Thurlow: [00:50:18] Lovely. It's so--
Dr. Robyn Roth: [00:50:19] [chuckles] Well, it's called Everyone Has Boobies, so you could find that at my website at everyonehasboobies.com. It's going for presale now and then it will be releasing in January. And I'm so excited about that because I really just want to destigmatize breasts and open up the conversation with the younger audience. I love what I do. I'm so passionate about it, obviously, and I'm so grateful to have been a guest on your podcast.
Cynthia Thurlow: [00:50:42] Absolutely. Such an honor.
Dr. Robyn Roth: [00:50:44] Thank you.
Cynthia Thurlow: [00:50:47] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend.