Mountain Health Today

Welcome to Mountain Health today, the show where we explore the people, stories, and innovations shaking health in this year. I’m Dr. Brian Evans, chief medical officer of Tahoe Forest Health System.

Each month, we take a few minutes to talk with local experts and the community leaders about what it really means to stay healthy physically, mentally, and emotionally here in the mountains. From everyday wellness to the latest advances in medicine, our goal is very simple.

To give you clear, trusted information that helps you and your family live well. So, thank you very much for joining us and let’s get started.

Today, we’re actually going to be discussing an absolutely crucial topic. It affects every community, including ours.

It’s about breast cancer screening and early diagnosis. We’re very fortunate to have a guest today, Dr. Kristy Howard.

Dr. Howard is a board-certified OB-GYN physician practicing full-time at Tahoe Forest Hospital. She provides full spectrum OB-GYN care to our community and has special interests including menopause as well as breast cancer screening and early treatment.

Dr. Howard, welcome to Mountain Health Today. Thank you so much for having me.

I think this is such a great series that we’re doing and I’m really excited to be a part of it. Well, we really appreciate your expertise certainly on this topic, but all you do for our community and patients with OB/GYN care, delivering babies, prenatal, postnatal, the whole gambit.

So, we really appreciate you being here. We’re talking today specifically about breast cancer screening and how important it is to make sure that people are getting diagnosed as early as possible.

Maybe you could give us a little bit of an idea about your background and what led you to focus on breast health and breast cancer screening specifically. Great.

Yeah, happy to share that. So, as you mentioned, I’m an OB-GYN.

I was drawn to women’s health and OB-GYN really for the opportunity to take care of women throughout their whole lifespan starting from adolescence or earlier and through menopause and beyond. And I think my practice has really kind of evolved over time the longer I’ve been doing this and that as I have aged with my patients.

I think that I really have focused more on menopause care and included that with breast cancer screening. And then recently, I think one of the things that really has kind of brought it to light for Tahoe Forest Hospital and myself is being a part of partnering with community health in outreach to really help reach people in our community that are not being properly screened for breast cancer.

We’ve taken note that there are folks in our community that are not getting the screening that they need. And you know, overall our rates are pretty good in California and in our particular community, but there are definitely women that aren’t getting the screening that they should get.

And I know that’s a passion for you to make sure that we reach them. There’s lots of folks in our community health department that are trying to figure out strategies to really get people the screening test that they need.

So, thank you for jumping in on that. What are some of those strategies to try to get people to get the screen?

Like how do you have this conversation with their patients and how do you reach people that aren’t even coming into the clinic to see them, right? That’s a good question.

I mean, I think the ones who are coming in and seeing us and doing their yearly exams, that’s kind of the easy population to capture. and you know, that’s what we do on a daily basis is just educating women, empowering women to take care of themselves and do these preventative screenings.

As you mentioned, I think the bigger issue comes in for the women who are not coming in. And so that’s what our big focus is, more with community outreach and trying to reach these women that are not coming in for their routine visits and getting this screening.

Some of the ways that we’re trying to work on that right now, we’re currently partnering with UC Davis, the community health department, this is something that they do so well is with the community outreach. We’re specifically trying to reach our Hispanic population. It is one of the groups in particular that has been underscreened in this community.

And so we’re partnering with them to get outreach materials not only written materials but going to community events where we can reach these women. Why does early screening make a difference?

If somebody feels great, they don’t have any symptoms, they’re not noticing any abnormalities with their breasts, why do they need to get a screening test? No, that’s a really great question and that’s kind of the whole definition of a screening test, right?

It is to detect something and to be able to prevent disease. The benefit of mammograms and breast cancer but it is the primary form of breast cancer screening is that it is able to detect small things that you wouldn’t be able to feel on an exam probably for many many years.

And it makes such a difference to detect these things and diagnose these cancers at an early stage. Not only is it an easier treatment in general, it can do a lot more conservative therapy typically rather than more extensive surgery and be a much more minor surgery, it can have the potential to avoid chemotherapy and a lot more detrimental treatment options that just can affect quality of life.

And so I think not only for the woman herself, but for her family and her support people, finding these things early makes such a difference in quality of life. So it really can be a life or death kind of a situation getting that screening test done.

It really can be. That’s absolutely correct.

I mean the mortality rate from breast cancer was so much higher before mammograms became mainstream which really didn’t happen till late 80s early 90s. and we’ve seen such a dramatic decrease in mortality from breast cancer because of early detection.

Yeah absolutely. So say a little more about some of the treatments.

I think people are familiar with the fact that if they are diagnosed with breast cancer, they may need radiation therapy, they may need surgical therapy, and they certainly are likely to know about chemotherapy. But if the screening is done and the diagnosis is made early on, some of those treatments may be less necessary or less intense or just less impactful to the patient and the family members.

Is that right? That’s absolutely right.

When we can diagnose these cancers at a really early stage more often than not women are able to avoid chemotherapy altogether and just do more limited surgery. We’re able to just remove the problem area rather than having to do a full mastectomy or remove the entire breast and then the adjuvant treatment that needs to happen afterwards can dramatically different it depending on how early these cancers are detected.

What are some of the reasons why some folks might want to avoid these screening tests? Are they concerned about discomfort or they’re afraid of getting bad news or what’s going on?

I mean, I think all of the above, right? I think that there’s a definite fear factor, not only just fear of the procedure itself and the unknowns that come with that, but the fear of getting that information and what you do with that information when you get it.

I think there’s a lot of misinformation, unfortunately, about mammograms where some women are worried that the mammogram itself is dangerous from a radiation perspective. And so I think that that limits some women.

And then unfortunately I think cost and access become an issue for a lot of women as well. A screening mammogram should be something that is routinely covered for all women.

But unfortunately some women either don’t know that or don’t aren’t properly connected to the avenues to help them financially not have to be paying out of pocket for these spring deaths. So we certainly do have options for that for folks that have limited resources and we want to make sure that every woman gets the screening test that is indicated and so you can reach out to Tahoe Forest Hospital and the imaging department and go on the website and figure out the various options.

There’s lots of help available and programs. So yeah, financially you know obviously in this country our insurance system being what it is and we don’t expect you to solve that today but it is a challenge out there but we don’t want financials to be a barrier for getting these screen tests.

That’s absolutely right and I think that’s another thing that Tahoe Forest Hospital is really doing a great job at right now and part of that project that I’m working on that I’d mentioned partnering with UC Davis for outreach but we’re also working internally to set up these channels to make it much easier for patients to reach financial financial counselors and know all the different programs and things that we have available in grants to help pay for these services for women.

Right. So some women are at higher risk than others for breast cancer.

So, when you’re seeing patients in your clinic, if you’re in your own community, how do you have that conversation with people and try to ascertain whether they do have higher risk and then do your recommendations potentially change as far as screening those individuals? Yes, that’s a really good point.

There are definitely women that are at high risk. The classic thing I think that most people are aware of is a family history.

Interestingly, the vast majority of breast cancers are actually diagnosed in women with no family history, but that is one of our kind of easily identifiable risk factors. Also prior radiation exposure, other lifestyle factors as far as obesity and alcohol consumption and all of these other lifestyle factors absolutely play a role.

So I think that part of these kinds of routine health screenings that we do is assessing the whole woman and the whole picture of what might be influencing her risk. There’s some really nice calculators that plug in all these different risk factors, just age and family history and previous exposure to things that can increase your risk of breast cancer.

And it’s nice because it really can kind of generate this lifetime risk for breast cancer. And it can help kind of guide us as clinicians like what kind of imaging is just a mammogram alone enough?

Do they need supplemental tests and things other than mammograms such as ultrasound and MRI and other tools that can be used? And so it’s definitely an individualized discussion with your healthcare provider kind of based on your own risk factors to see what is going to be best for you. 

Let’s talk about some of those other modalities because when people think about breast cancer screenings, they first think about mammograms, but there is a lot of discussion around MRI as potentially a modality that might be used more in the future, especially for breasts that are dense. Why would that be?

Yeah, that’s a really good thing and it’s definitely a hot topic lately. I think we’re seeing a lot of conversation about this happening. It is something that is assessed at the time of your mammogram is the level of density and there are different gradings based on how dense your breasts are.

And the more dense that tissue is can affect not only the accuracy of mammogram but it also puts a woman at an increased risk of breast cancer when you do have that more dense tissue. And so that’s another one of those factors that does get calculated in those risk predictions and that’s where MRI can really play a crucial role in the early diagnosis for women with the extremely dense tissue.

It’s not meant to take the place of a mammogram. It’s meant to be a supplement and adjunct to mamogram.

Ultrasound similarly is used in this situation. MRI for sure is the preferred study and more and more becoming the preferred study.

But again the cost and finances can always come into play with that conversation. Absolutely.

So you talked a little bit about some people having higher risk than other people. Family history is one of those things.

And there’s genes, right? There’s some people who carry particular genetic changes or abnormalities that put them at higher risk. How would someone even start to figure out if that’s them or they are one of those people?

Would they typically have a family history that they know about or how do you have those conversations? For both and more often that’s you know that’s how women got to our attention typically is from the family history.

And now this genetic testing is so widely available. We offer it through the women’s center. I know primary care offers it in a lot of places. I think you can just order online now yourself to get this information. But I always suggest talking with a physician or your provider so you can have better counseling once you get those results rather than just ordering it online.

But yes, there’s a lot of genetic testing available to identify these women and those really are the women that are at the highest risk. Not everybody with a family history has these hereditary genes, but those women who do particularly the BRCA gene we know puts women at a substantially increased risk of breast cancer.

And these are the women that really need to be followed more closely with not only mammograms but MRI on a regular yearly basis and maybe earlier in life. Correct.

So now for folks that are let’s say average risk, they don’t have the BRCA1 gene or they don’t have any other reason to think that they’re higher risk. Is it 40 that folks are supposed to get their first mammogram or it used to be 50, right?

It used to be 50. Well ACOG the American College of Obstetricians and Gynecologists as well as the American College of Radiologists both recommend starting yearly screening at age 40.

It’s pretty unanimous after age 50 that this should be done yearly. There were some differing opinions for women in their 40s whether it should be yearly or every two years.

Kind of the shared decision with their provider has always kind of been the recommendation for women in their 40s but more and more the push is towards starting yearly at age 40. Okay.

Yeah. So I mean it never hurts to say well talk to your doctor and kind of assess the risk.

We do know that breast cancer is more common as we age. That’s right.

But that doesn’t mean that it doesn’t happen to younger women as well. So we want to think about all of those folks.

What happens after somebody has a mammogram and there’s something abnormal there. This is a fairly intense situation for patients and family members as well.

So how do you handle that sort of finding and walk them through the process? Ideally when I get to counsel a patient before she’s actually had the mammogram, I like to do anticipatory counseling about the possibility of what people refer to as the call back.

That’s after you go in for your routine screening mammogram and you get a call saying we need you to come back in. About 10% of women will get a call back and that is much more common the younger you are.

Most of those call backs do not result in a diagnosis of cancer. It just means they need a closer look.

A diagnostic mammogram uses the same technology but takes more images and different angles. That can be followed by ultrasound or sometimes biopsy if needed.

We try to prepare patients so they understand what might happen so the anxiety is lower if they get that call. Breast cancer treatment has improved so significantly and we have invested heavily in technology including 3D mammography at Tahoe Forest Hospital.

We also have MRI, ultrasound, biopsy capability, and navigation support including genetic counseling. Having access to that full system matters.

We also have a cancer center in Truckee and it is a remarkable resource. We work closely with them and communication is excellent.

Even after a cancer diagnosis, patients continue routine care with us and the cancer team. Care is very coordinated across providers.

Most women still consider OB/GYNs part of their primary care team, even though we encourage partnership with primary care physicians. Preventive care is shared across the system.

Key points are screening should start discussion early, usually age 40 for average risk. Screening type depends on risk factors like breast density and family history.

And the best outcomes come from individualized conversations with your provider. Artificial intelligence is also starting to be used in imaging interpretation.

I haven’t had many patients ask about it yet, but radiology is increasingly using AI to support accuracy. It does not replace radiologists but works alongside them.

It can help improve detection and reduce false positives. Overall it is another tool to improve care.

Thank you, Dr. Howard, for sharing your expertise today. This concludes Mountain Health Today.

I’m Dr. Brian Evans, Chief Medical Officer of Tahoe Forest Health System. Caring for this community is a privilege and these conversations help us stay connected to your health and well-being.

You can learn more at tfhd.com. Until next time, take care of yourselves, take care of each other, and stay healthy in the mountains. Thank you.