[00:00:00] Adam Walker: From Susan G. Komen, this is Real Pink, a podcast exploring real stories, struggles, and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room.
Dr. Elizabeth Morris MD is a professor and chair of the Department of Radiology at the University of California Davis. She’s a clinician and specializes in high risk breast cancer screening. A pioneer in the field of breast imaging, she is at the cutting edge of research using screening techniques like MRI, Magnetic Resonance Imaging in conjunction with artificial intelligence to identify people at higher risk for breast cancer earlier so they can receive more screening and catch breast cancer earlier. Her Komen work combines screening images, patient health information, genomics, and uses artificial intelligence to predict individuals at higher risk for breast cancer in hopes of making a better model to identify those who would benefit from earlier or more frequent breast cancer screenings. Dr. Morris is here today to talk to us about her passion for early detection and to help us understand when we should be getting screened for breast cancer. Dr. Morris, welcome to the show.
[00:01:15] Elizabeth Morris: Hello. I’m very, very happy to be here.
[00:01:18] Adam Walker: Well, I’m very happy to have you. Let’s start with an introduction to our listeners.
As a clinician, you see patients. What drew you to this particular interest in breast cancer screening?
[00:01:30] Elizabeth Morris: Well, I love working with a field where I feel that I can save lives and I can save lives in partnership with patients who also are part of the decision making process. And so it’s directed usually towards, women who are generally healthy and they’re trying to stay healthy. So it’s a very appealing field for me because it’s sort of keeping people engaged, alive and on track for a better life. And so that’s why I’m like a major, passionate advocate for women to get screened and to have the benefit of those extra life years.
[00:02:20] Adam Walker: So, Dr. Morris, understand you’re passionate about personalized screening. Tell us what that is and why it’s important.
[00:02:28] Elizabeth Morris: Well, I, it’s the idea that we’re all very different and we all carry different risk factors. We’ve had many decades of population-based screening where there are recommendations, blanket recommendations for pretty much everyone which is a really great place to be and start. But then over time, especially with now that we’re able to do genetic analysis and look at people’s risk profiles, and we understand that different women have different risks for breast cancer, it sort of moves us into an era where we can tailor screening for each individual woman and that’s called personalized screening.
[00:03:15] Adam Walker: Got it. And so that’s personalized screening. And I just want to make sure I understand. So. Historically it’s generic. So you go do this at this age, right?
[00:03:24] Elizabeth Morris: For example, yeah. For historically it’s been ev there are guidelines that have been released by different societies, and particularly in the United States. It can be very confusing for women. As well as providers to understand the different guidelines. It’s really important to understand that the data that the guideline committees for all these different organizations use is the same, but the organizations have different values. And so their guidelines may be different from other organizations.
For example, those of us who work with breast cancer patients and are in the breast cancer field recommend that women start being screened. an average risk woman should be screened annually. That means every year starting at age 40 and that there is no cutoff. If it’s expected that she has 10 years of life she should still be screened. So as we all are getting older and we’re living into our eighties, nineties, and even hundreds, that means that women can be screened theoretically up in, in the, into their eighties. And so that’s an important concept.
The other thing is, that the societies who work with patients in the breast cancer field recommend that you have it every year. You screen every year. And that is because if you do it every year, you have a chance of catching those cancers that can be somewhat aggressive earlier and treat them earlier. There are new guidelines that have come out just actually last week from what’s called the USPFTF, and that is the Federal Guideline Committee that has recommended starting screening at age 40. Which is a really good step because previously they recommended starting screening at age 50, so it’s really great that they have moved the start date. To the forties, but they’re still recommending every two years instead of every year. And they are also recommending that you stop at the age of 75. So those guidelines are a lot more restrictive. They’re the guidelines that a lot of institutions use, but, they’re very, they exclude a lot of women that should be screened. So I don’t support those guidelines. Yeah. I support annual screening for average risk women, age 40 and above.
[00:06:07] Adam Walker: And personalized screenings, like take it one step further. Right. So I assume they take in other factors like family history or-
[00:06:14] Elizabeth Morris: Yes.
[00:06:14] Adam Walker: Dense breast tissue or things like that, right?
[00:06:17] Elizabeth Morris: Yes, absolutely. So both of those things that you mentioned raised a woman’s risk, and that’s why society such as the American College of Radiology or the Society of Breast Imaging, recommend that all women should, by the time they’re 30 or in their thirties, understand their risk factors. Because if you know your risk factors, and if you talk to your, say your OBGYN or your primary care physician and you talk about your family history or maybe some other things that have happened in your in your life then there can be an assessment. Are you high risk? Are you low risk or are you intermediate risk? And then the recommendations for screening can be adapted to that.
[00:07:06] Adam Walker: Got it. Got it. Okay, thanks that, that’s really helpful. Are there any myths or misconceptions about breast cancer screening or detection that you encounter when you’re working with patients in the clinic?
[00:07:17] Elizabeth Morris: Yes, there are. First and foremost, many people get worried when they feel a painful lump in their breast. So say that they are taking a shower and they feel a lump and it’s a little bit painful. They are worried that it might be cancer. In general, cancer is not painful. It is usually painless. Although of course, there are always exceptions to the rule. But the important thing here is that if any woman feels anything she’s concerned about, she should go in to get it checked out. And she should go to either a physician who can give her a referral to get an ultrasound. Anytime anything is felt in the breast, it needs to be checked out.
[00:08:09] Adam Walker: Got it. And that’s actually really helpful. I’ve never heard anyone say that cancer is usually pain less. So that’s a really interesting distinction. I had not thought of that before. I appreciate you sharing that. The general recommendations and I think we’ve kind of talked about this, but I want certainly want to elaborate a bit more.
The general recommendations is for women to begin receiving annual screening mammograms at age 40 if they’re at average risk. But how does someone know when to begin screening and if they may be at high risk?
[00:08:39] Elizabeth Morris: So it, it can be a little bit complicated but if you have, say for example, a first degree relative either say your mother or your sister who had breast cancer and they had breast cancer at age 45. The general recommendation is that you need to start screening 10 years earlier than that patient, than your first degree relative had. So you would start screening at age 35. Now if you had a mother or sister who had breast cancer at age 35, you would start screening at 25. We generally don’t screen under the age of 25 just because breast cancer or at least breast tissue is still developing and you don’t want to radiate breast tissue.
Many people know that they have a family history of breast cancer and they may get tested. Many people are getting tested with, the 23andme and all these different genetic tests that are out on the market. And they may find out that they have genetic mutation that predisposes them for breast cancer like a BRCA one or two, or P10 or, ATM, there’s a lot of different markers out there. And in that case, if they find that they have one of these high penetrance genes, then we generally start screening with MRI. And so we start screening as soon as the patient gets diagnosed with that mutation. So, and that’s on a yearly basis. So, so those patients get, not only mammography, but they also get MRI.
[00:10:27] Adam Walker: So, so I wonder if you could talk a little bit more about the MRI too, like while we’re on that topic, like, like, that’s one reason they’d get an MRI. Are there any other reasons they would get one?
[00:10:36] Elizabeth Morris: Yeah, there’s a lot of other reasons that there’s some new data out that show that women who are even average risk and have dense breath benefit from getting an MRI.
So an MRI, the MRI itself is not probably the important thing. What’s important is that you’re getting a contrast injection. And so, a mammogram just looks at sort of the anatomy and looks to see are there any changes in the anatomy. But an MRI actually is a functional test, and it can see the contrast going to these very small breast cancers that may be impossible to pick up on the mammogram. So, so it’s really been shown to be able to pick up small breast cancers that are under a centimeter most of the time and that are node negative. So MR screening is what I would call the the top of the line test we have for breast cancer screening. We have other tests now that are somewhat similar and less expensive and somewhat easier to get, and that includes contrast mammography.
So contrast mammography is just getting a mammogram with an injection of contrast, and it’s very similar to an MRI scan, you can pick up these small breast cancers a lot earlier that, that you otherwise wouldn’t see on the mammogram because of the masking of all the dense tissue.
[00:12:08] Adam Walker: Gotcha. That’s great. I appreciate you walking me through that. So we know that women are at highest risk for breast cancer, but it’s not a disease that’s exclusive to women, men, or transgender people can get breast cancer and may not receive the same amount of screening or education about their breast cancer risks.
So what kind of screening guidance exists for men or trans individuals, particularly for those who are at high risk?
[00:12:34] Elizabeth Morris: So, generally for men particularly even those who are BRCA positive we generally don’t recommend screening. But there are some centers where screening can occur if the patient requests because men generally in, they have much smaller breasts, and so the, if a breast cancer does develop, it’s easily palpable, meaning you can feel it. You can go in and get regular just examinations and that should be sufficient.
Now, when you’re talking about transgender, that’s a whole new field. For us in imaging, breast imaging there are recommendations that have come out from the American College of Radiology about imaging transgender patients.
Generally, if you have a female to male transition and you have top surgery, there are no recommendations. You don’t need to be screened because you, essentially you’ve had bilateral mastectomies and all of that breast tissue should have been removed. The recommendation is similar to a man where you would have physical examination, but you wouldn’t have a mammogram.
If you’re a male to female transition and you have been taking hormones, if you’ve been taking hormones for over five years, Then you should start screening. And it’s the regular guidelines that it would be for annual starting at age, 40 and above.
[00:14:11] Adam Walker: Got it.
[00:14:12] Elizabeth Morris: And then it gets complicated when you might have someone who, for example, if you had a female to male transition and they had already had a biopsy and had a high risk lesion and they’re high risk, or they have a BRCA carrier, then it becomes a more complicated because if they didn’t have that bilateral mastectomy, they would be eligible for MRI screening. So it depends on, how much native breast tissue remains for female to male transition and for male to female transition. It depends on how long you’ve been on hor estrogen or, similar types of hormones.
[00:14:54] Adam Walker: Got it.
[00:14:55] Elizabeth Morris: This is actually very interesting to me because I, my, my son is my oldest son is trans. Yeah. So, and had bilateral mastectomies, yeah.
[00:15:07] Adam Walker: That’s, I mean, it’s important. It’s important to, to understand the all of the health issues around this.
[00:15:16] Elizabeth Morris: Yeah.
[00:15:17] Adam Walker: So I understand that you’ve recently been diagnosed and treated with breast cancer. Did that change how you practice at all or any of your interactions with your patients?
[00:15:27] Elizabeth Morris: Yes, it’s made me a much stronger advocate for women with dense breasts and for getting them additional testing so that we can pick up early breast cancer. In my situation, I have extremely dense breasts and I, my cancer was not seen on mammography. Or on tomosynthesis which is 3D mammography, and it was also not seen on screening ultrasound. And because I don’t have a family history of breast cancer, I did not get an MRI. But in all honesty, I should have based on recent data that show that women with extremely dense breast benefit from MRI screening. So my cancer was found in incidentally with surgery and I am ex. Extremely lucky because it was very small and, but it did not get detected on on testing. So I have strong belief that it would’ve been picked up if I had contrast-based testing, either with an MRI or a mammogram. So I think for me, when I, whenever I see women with dense breasts, in the clinic, I always, bring up that conversation with them that they may want to consider to have some kind of contrast based screening, because I know I’m going to miss cancers looking at those exams.
[00:17:02] Adam Walker: Yeah. Yeah, that’s great. I love that it’s made you even more passionate about that. How, I mean, it’s just so important for people to be able to understand that you can empathize and that you’re-
[00:17:12] Elizabeth Morris: Yeah
[00:17:12] Adam Walker: you’re walking that same path.
[00:17:13] Elizabeth Morris: Oh, I do.
[00:17:15] Adam Walker: Well, Dr. Morris, last question. Do you have any final advice that you’d like to share with our listeners?
[00:17:22] Elizabeth Morris: Yes. I think just get your mammogram and find out your risk. Getting the mammogram is the most important part. Even though there are limitations with mammograms, they can still pick up quite a lot of breast cancer. So, only 60 to 70% of women who are eligible are getting their mammograms.
So I would encourage everyone to make that appointment and and get there to get the mammogram. The risk part is a little more trickier. You need to have a conversation with your primary care physician or your whoever is taking care of you, you may want to do some research online. Talk to your family members find out does someone have breast cancer or some other type of cancer? Find out if you have dense breasts. That’s very important. And if you do, try to advocate for additional screening, either with contrast based screening, which is the best that’s with MR or mammography. But if you don’t have access to that, then ultrasound also is very helpful to pick up cancers that can’t be seen with the mammogram.
[00:18:36] Adam Walker: That’s great advice. That’s great advice. Get screened. That’s the, that’s at the end of the day get screened.
[00:18:42] Elizabeth Morris: Yes.
[00:18:42] Adam Walker: So, so important for your health. Well, Dr. Morris, thank you for breaking down some of these complexities for us. Thank you for your time today and for joining us on the show.
[00:18:51] Elizabeth Morris: Thank you so much.
Thanks for listening to Real Pink, a weekly podcast by Susan G Komen. For more episodes, visit real pink.komen.org. And for more on breast cancer, visit komen.org. Make sure to check out at @SusanGKomen on social media. I’m your host, Adam. You can find me on Twitter @AJWalker or on my blog adamjwalker.com.