Co-Pilot Your Breast Health with Dr. Rachel Brem
about the episode
Do Mammograms Miss Cancer in Dense Breasts? Dr. Rachel Brem on Breast Screening, Risk & Prevention
On this episode of Innovate and Elevate, Sharon is joined by Dr. Rachel Brem. Dr. Brem is board-certified in Diagnostic Radiology. She is a Professor of Radiology, the Vice Chair of Radiology, and Director of Breast Imaging & Intervention at The George Washington University School of Medicine & Health Sciences.
In this conversation, Dr. Brem shares how to understand your risk for breast cancer and her recommended imaging strategy for those with dense breast tissue. She also emphasizes the importance of co-creating a personalized healthcare plan with a doctor that suits your needs.
Dr. Brem outlines common factors that put women at an increased risk for breast cancer:
Age forty or over.
Dense breast tissue.
First-degree relative with breast cancer.
Genetic mutation (or greater than 20% lifetime risk of breast cancer).
Unusual findings (atypia) or prior history of breast cancer (15-19% increase).
Note that other risk factors may influence your individual situation. For a comprehensive understanding, explore additional resources at breastcancer.org/risk/risk-factors.
Cancer in a dense breast is exponentially more difficult to detect in a mammogram, which is why Dr. Brem is a strong advocate for breast ultrasound and/or MRI. In fact, breast imaging specialists can find 25% more cancerous cells with ultrasound screening in women with dense breasts than they can with mammography.
Dr. Brem doesn’t believe in a one-size-fits-all breast healthcare approach. Instead, she urges women to get the knowledge they need to make the right choices for their health and find a doctor that can tailor a plan for their unique needs.
Finally, Dr. Brem shares her hope in the technologies currently in development to help detect cancer before imaging, such as liquid biopsy and breath analysis.
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“Do not accept less than what you deserve, which is optimal care. The real message is: Don’t rely on others to find out for you.”
About Dr. Rachel Brem
Dr. Rachel Brem is an expert in the field of breast imaging and intervention. She is the Director of Breast Imaging and Intervention as well as a Professor of Radiology at The George Washington University Medical Center. Dr. Brem serves as the Director of the Breast Imaging and Intervention Fellowship at The GW Medical Center, as well as the Vice Chair for Research and Faculty Development in the Department of Radiology at GW.
Connect with Dr. Rachel Brem on LinkedIn.
Episode Outline
01:23 Dr. Brem’s Personal Breast Cancer History
04:49 Be In The Driver’s Seat: Know Your Breast Cancer Risk Level
08:32 Know Your Options: Talk With Your Doctor About A Personalized Risk-Based Screening Plan
12:52 The Future of Early Detection
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Sharon Kedar 00:02
Behind every pioneering idea, method, and device is a fellow human or humans, a trailblazer who is daring enough to ask the questions that push the boundaries and make the impossible possible. I'm Sharon Kedar, Co-Founder of Northpond Ventures, a multibillion-dollar, science-driven venture capital firm, and the host of Innovate and Elevate. In each episode, we'll have candid, in-depth conversations with top doctors, scientists, and innovators, about leading-edge discoveries and how they impact our lives. Season one focuses on women's health, with the aim of helping women lead our healthiest lives. You'll hear from leading experts, such as Dr. Kathryn Rexrode, Division Chief Women's Health at Harvard's Brigham Hospital. It's time for all of us to Innovate & Elevate.
Sharon Kedar 00:53
We have the brilliant Dr. Rachel Brem today on the podcast. Dr. Brem is board-certified in diagnostic radiology. She is a Professor of Radiology and the Vice Chair of Radiology at The George Washington University School of Medicine and Health Sciences. She is also the Director of Breast Imaging and Intervention. Dr. Brem has her own foundation, The Brem Foundation. Dr. Brem, welcome to the podcast.
Dr. Rachel Brem 01:20
Thank you so much. I'm thrilled to be here.
Sharon Kedar 01:27
If I may ask about your breast cancer history, I think the audience would really appreciate hearing your story and context before we get into taking the listener and the viewer into your doctor's office.
Dr. Rachel Brem 01:43
Absolutely. I became a radiologist, and then I subspecialized in breast imaging, and shortly afterwards, while I was at Hopkins, I was the Director of Breast Imaging at Hopkins. I was charged with finding equipment that we needed. We needed an ultrasound unit, and so what I would do is after a day of seeing patients, I would ask all the vendors to bring their machines in and then try it out on myself. I did indeed figure out which ultrasound machine we were going to buy, but I also found my own breast cancer. Here I am, scanning, and there was no doubt in my mind what it was.
There was this rush of emotion. First of all, I felt profound gratitude that I knew what I wanted. I couldn't understand how my patients dealing with the very same situation had to make these incredible decisions without the kind of lifelong commitment to education and practice within the field of breast cancer. The other thing was that it was another example of early detection. We weren't supposed to use this technology.
Dr. Rachel Brem 02:46
But it was almost prophetic, because now we use a lot of ultrasound for screening. And we know how effective it is in women with dense breasts. I felt, even at that point, it was perplexing to me why we aren't using ultrasound for screening. I ended up spending a fair amount of my career really focusing on ultrasound screening and women with dense breasts. I found my own breast cancer, but it was an interesting time because it was 1996. And in 1994, the BRCA gene was identified. My mother had had breast cancer at a very young age. We are Ashkenazi Jews, although we only know that later, but a lot of Jews had breast cancer. And I had decided that I would get tested for the BRCA gene. And I was tested, I turned out positive on BRCA1 positive. And I remember saying to my husband that if I don't have the gene that we will have another child and if I do have the gene, I'm gonna have prophylactic mastectomies. There wasn't a lot of data.
Dr. Rachel Brem 03:41
We didn't know what that did. Now, we know that it's a very reasonable consideration for people at substantially increased risk, people who have the gene like I do, but I just knew that I had to do that. I had already been scheduled for prophylactic mastectomies, and I was gonna have my ovaries out at the same time as well. And between scheduling my surgery and having it is when I did this and found my own breast cancer,
Sharon Kedar 04:10
How old were you? Just so the audience knows.
Dr. Rachel Brem 04:12
Thirty seven. I learned another really important lesson that cancer takes its own timeline. You think you can outsmart it, but you may or may not be able to. And of course, many women have successful prophylactic mastectomies these days. But, I missed my window of opportunity and I went from having prophylactic mastectomies to having breast cancer and a prophylactic mastectomy on the other side. I tried to outsmart cancer. Cancer didn't let me but that doesn't mean that other people can't do that.
Sharon Kedar 04:48
Dr. Brem, when it comes to breast cancer, how does a woman know if she is high risk or low risk?
Dr. Rachel Brem 04:55
The definition of high risk is if you have a 20% or greater lifetime risk of developing breast cancer, and intermediate risk is 15 to 20%, and average risk is below 50. So how do you know that? Well, there are certain things that put you automatically into a higher risk. One is if you have a genetic mutation that is associated with a high risk of breast cancer. If you've had a personal history of breast cancer, you are at much higher risk and at a high risk of developing another breast cancer. If you've had a biopsy that shows these unusual findings, called atypia, you're at higher risk. The older you get, the higher your risk of breast cancer, throughout life. That doesn't mean that every older woman is at high risk, lifetime risk of breast cancer, but it means that together with these other factors, as you get older, your risk of developing breast cancer increases.
Sharon Kedar 05:46
For a woman who knows that, in their family, there's a family history of breast cancer, a mother, an aunt, what is the rule of thumb for the age that that woman needs to start screening?
Dr. Rachel Brem 06:00
That's a great question. Every woman should start screening 5 to 10 years earlier than the age that their single first-degree relative or two second-degree relatives developed breast cancer, so if your mother developed breast cancer at 40, you should start screening at 30 to 35. But the extension of that question is if I had the gene mutation, when should I start screening? The answer is probably not before 25, because there's no intervention before and between 18 and 25, it's a hard time emotionally to process the information of a gene mutation, and you're not going to do anything about it anyway.
Really, the best way to find out if you're at high risk is to take one of these online available tests, one of which is one that was launched by The Brem Foundation recently called CheckMate.
Dr. Rachel Brem 06:53
It's a very simple, three-minute interactive tool that will determine if you should at least have a discussion with your healthcare provider about being at high risk and needing additional testing. There are many online, Tyrer-Cuzick, Gail. You certainly can ask your doctor to help you find the mechanism to determine if you're at a high enough risk that you need an MRI, but every woman who has dense breast tissue is at least at intermediate risk of breast cancer and should have additional screening with ultrasound or MRI.
Sharon Kedar 07:24
How much less effective are mammograms for women with dense breasts?
Dr. Rachel Brem 07:30
Great question. If you have almost no breast density, what we call A density by the BI-RADS categorization, then mammograms are 90+% effective. If you have the dense breasts. C and D, we miss 50, in some studies up to 60% of breast cancers. Having dense breast tissue is a big deal, because it happens in half of American women, and it makes mammograms so much harder to read, and it increases your risk of breast cancer. It's like the perfect storm. We do have ways to find these hidden cancers. If you have dense breast tissue, you should at least have an ultrasound every year, either at the same time of your mammogram or spaced out by six months, because we can find 25% more of these important breast cancers when we do ultrasound screening in women with dense breasts.
Sharon Kedar 08:35
What's really important for the viewer and the listener to understand is you need to get information for yourself about your doctor. You need to know if your doctor has certain views versus other views, what are their biases, are you aligned with that? Because there's different screening philosophies, and just understanding that, it's not like getting a flu test. This is a controversial area about how much screening to do.
Dr. Rachel Brem 09:03
I think what I would say is that women have to get the knowledge for themselves, and be empowered with the information for them, so that even if their doctor is not aligned perfectly with them for the optimal breast cancer screening which is appropriate for them, that they need to know what that is and they need to advocate for that. Maybe the real message is don't rely on others to find that out for you.
Sharon Kedar 09:30
Mammography being the primary screening tool that we have today as a start, how should a patient think about when they go get a mammogram?
Dr. Rachel Brem 09:39
You should insist that whoever interprets your mammogram does a lot of mammography. At our institution, all the breast imagers, all the radiologists who do breast imaging do nothing but breast imaging. That's the best, but at least 70% breast imaging, and you have the right to ask, "Who's going to interpret my mammogram? I want someone who does 70% mammography or breast imaging to do it." Then, if you have dense breasts, raise your voice and insist on getting at least an ultrasound, if not an MRI.
Sharon Kedar 10:08
When it comes to ultrasound, your belief is that any woman with dense breasts should have an annual screening ultrasound. You wrote about that so beautifully. Get the book if you don't have it, No Longer Radical. Such a helpful book, published last year. Can you talk about why we are not in that place today?
Dr. Rachel Brem 10:31
If you have dense breast tissue, you really do need additional tests, and that could be an ultrasound, it could be a contrast-enhanced mammography, it could be molecular breast imaging. Contrast-enhanced mammography, molecular breast imaging, and MRI all require an injection. Ultrasound does not. It's a quick-and-easy test that a plastic piece goes over your entire breast. There's probably a little bit of compression, but it's not painful, it's not difficult. It is not the standard of care today.Part of the reason is that we don't have enough resources in this country to do that for the half, the 50% of women who have dense breast tissue, and that's just the reality. We don't have the manpower to do it.
Dr. Rachel Brem 11:31
Now, if you're going to pay out of pocket, it is a very expensive test, and most of the time, it really requires insurance coverage. If you're going to pay out of pocket, I would say there are an increasing number of out-of-pocket screening MRI programs that use what's called abbreviated breast MRI, that are faster, still require this injection, but sometimes, you can pay out of pocket for as low as $250.
Sharon Kedar 11:51
If a woman has a choice between the standard MRI and the abbreviated MRI, do you have a perspective on which is better?
Dr. Rachel Brem 11:57
They're both fine for screening purposes.
Sharon Kedar 12:00
When is MRI standard of care in today's world?
Dr. Rachel Brem 12:04
MRI's standard of care if you have a gene mutation, that affords markedly increased risk of breast cancer, like BRCA1, BRCA2, but there are many other, CDH1, p53, many. There are over 70 genes that have been identified with a markedly increased risk. If you had Hodgkin's lymphoma and were radiated as a teenager or young adult, your risk of breast cancer is extremely high, and in certain other high-risk populations. It turns out, if your lifetime risk is 20% or greater, then you will be eligible for MRI. Almost every insurance company will cover it. The problem is that every risk assessment tool is different, so one risk assessment tool might make you 15% and another might make you 25%. It's not an exact science. But, 20% lifetime risk or greater, MRI should be covered by your insurance company, but there is a copay and a deductible, as of now.
Sharon Kedar 12:55
What do you see on the horizon in terms of new modalities for early detection?
Dr. Rachel Brem 12:59
What I see on the horizon is one step before imaging. The ideal is a couple of things. It is to find it even before we can see it, and there are increasing technologies being developed, things like liquid biopsy, things like breath analysis, looking for volatile organic compounds that may be an indicator of cancer or non-cancer. Not here yet. Many other technologies are being developed to think about early detection even earlier than we think of it now, and I can't help but believe that our survival will be even better.
Sharon Kedar 13:34
Dr. Brem, thank you. You have been such an inspiration. For all the viewers and listeners, please check out Brem Foundation, and also Dr. Brem's book, No Longer Radical. It's a great primer to understand your risk level, and it's a great follow-up to this podcast. Thank you again for being on the podcast.
Dr. Rachel Brem 13:53
Thank you so much for this. It's been wonderful.
Sharon Kedar 14:07
Thank you for tuning in. Please connect with me, Sharon Kedar, on LinkedIn for additional innovative content. If you enjoyed this episode, please take a moment to like it, and don't forget to subscribe to the channel by clicking the button below this video. The views and opinions of the host and podcast guests are their own professional opinions and may not represent the views of Northpond Ventures.
About Your Host
Sharon Kedar, CFA, is Co-Founder of Northpond Ventures. Northpond is a multi-billion-dollar science-driven venture capital firm with a portfolio of 60+ companies, along with key academic partnerships at Harvard’s Wyss Institute, MIT’s School of Engineering, and Stanford School of Medicine. Prior to Northpond, Sharon spent 15 years at Sands Capital, where she became their first Chief Financial Officer. Assets under management grew from $1.5 billion to $50 billion over her tenure, achieving more than 30x growth. Sharon is the co-author of two personal finance books for women. Sharon has an MBA from Harvard Business School, a B.A. in Economics from Rice University, and is a CFA charterholder. She lives in the Washington, DC area with her husband, Greg, and their three kids.
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Connect with Sharon on LinkedIn: Sharon Kedar
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faqs
What are dense breasts?
On Innovate & Elevate, Dr. Rachel Brem explains that dense breast tissue refers to breasts with a higher proportion of glandular and fibrous tissue relative to fatty tissue. Dense breasts are common and may affect both breast cancer risk and how imaging is interpreted.
Can mammograms miss cancer in dense breasts?
On Innovate & Elevate, Dr. Rachel Brem explains that dense breast tissue can sometimes make abnormalities harder to identify on mammograms. The conversation explores why additional screening approaches may sometimes be considered depending on individual risk factors.
How do women know their breast cancer risk?
In this Innovate & Elevate discussion, Dr. Rachel Brem explains that breast cancer risk assessment may involve family history, genetics, breast density, lifestyle factors, and clinical information.
What is personalized breast screening?
On Innovate & Elevate, Dr. Rachel Brem explains that personalized breast screening moves beyond a one-size-fits-all model by tailoring recommendations according to individual risk profiles.
When should women begin breast cancer screening?
On Innovate & Elevate, Dr. Rachel Brem discusses how screening timing may depend on family history, genetics, risk factors, and conversations with healthcare providers.
Why is breast density important?
On Innovate & Elevate, Dr. Rachel Brem explains that breast density may influence both screening effectiveness and breast cancer risk discussions.
Can women become active participants in breast health decisions?
In this Innovate & Elevate conversation, Dr. Rachel Brem encourages women to understand their health information, ask questions, and participate actively in screening and prevention decisions.
Why is prevention important in breast health?
On Innovate & Elevate, Dr. Rachel Brem explains that prevention includes understanding risk factors, engaging in screening, and recognizing the importance of early detection.
How is breast cancer screening changing?
On Innovate &Elevate, Dr. Rachel Brem discusses how breast health is increasingly moving toward individualized, risk-informed screening approaches designed to improve outcomes and patient care.