RANDY HICKS, MD: The controversy regarding screening mammography

During a recent The Breast of Everything podcast, Breast Surgeon Linsey Gold, DO; talked with Radiologist Randy Hicks, MD; about questions women are asking regarding mammography screenings and the use of technology in detecting breast cancer in its earliest stages. Dr. Hicks is co-founder and co-director of Regional Medical Imaging, serving physicians and patients throughout mid-Michigan and southern Michigan for the past 35 years. 

There is a lot of controversy regarding screening mammography – when to do it, who should do it and how it should be done. As a result, women often are confused and don’t know where to turn for credible, consistent and accurate answers.

Dr. Hicks and his team of radiologists believe women should have a baseline mammogram at age 35 and then yearly screening mammograms beginning at age 40. The American Cancer Society and the American College of Radiology agree on this. 

Risk stratification increasingly is becoming key in the detection of breast cancer, Dr. Hicks finds. Each woman has her own individual risk factors for breast cancer and every woman should be aware of what they are. The “one size fits all” model no longer works when it comes to screenings and treatment for breast cancer.

A woman’s breast density also is an important factor for physicians and patients to know, Dr. Hicks points out. The denser the breasts, the harder it is to identify cancer.

About 25 percent of women have dense breasts and about 50 percent of those cancers are missed in a mammogram. However, “we have other technologies we can use to see through the density,” Dr. Hicks assures patients. 

These are: 3D mammography, whole breast screening ultrasound, contrast enhanced mammography, nuclear medicine and screening breast MRI. 

Transcript

Unknown Speaker  0:01  
Welcome to the breast of everything podcast your trusted resource for breast health information support and encouragement. Your host today is Dr. Lindsay gold of comprehensive breast care. Welcome.

Unknown Speaker  0:12  
Welcome, everybody to the breast of everything Podcast. I am your host today, Dr. Lindsay gold. Thank you so much for joining us. Today we have a very special guest. This is Dr. Randy Hicks, who is a Board Certified radiologist. And we are really lucky to have him say Hello, Dr. Hicks.

Unknown Speaker  0:35  
Hello, Dr. Gold and everyone else I appreciate your having me.

Unknown Speaker  0:39  
Let me tell you a little bit about Dr. Hicks. He's really quite amazing. He owns or is co owner of a company called regional medical imaging, which is an independently owned and operated imaging company serving the entire state of Michigan. Dr. Hicks has been in business for more than 35 years, and he and his partner Dr. David straily, have dedicated their entire careers to advancing the use of technology to detect breast cancer as early as possible. In an attempt to give women the best chance they have at surviving the disease. Dr. Hicks has led Regional Medical Imaging team in growing the practice which now encompasses nine imaging centers throughout the area that provides state of the art techniques to detect and biopsy breast cancers with minimal delay or disruption to a woman's normal routine life pattern. These diagnostic techniques allow for a rapid diagnosis and a clear path to treatment. Also, Dr. Hicks has been a thought leader in the radiology industry, and has worked with the industry giants such as GE, Siemens, IBM, Hologic and icad to mention a few. He pushes the envelope to discovering new techniques and technologies to hunt down and diagnose breast cancer. His passion is really palpable, which you'll hear today. And his energy is relentless in this hunt as time does matter in the diagnosis of breast cancer. So Dr. Hicks, there is a lot of controversy in the lay media, and over decades of time, about screening mammography, when to do it, who should do it, how it should be done. And I think a lot of this can really leave women confused. And even when women go to their health care providers, family doctors OBS they sometimes get mixed advice. So I think if we start out with where are we today with screening mammography in the country?

Unknown Speaker  2:56  
Well, it is, as you have stated, it is a very confusing situation in the sense that throughout the country, you know, we have had a lot of different opinions rendered by major national leaders. So that's left not only the women in somewhat of disarray, but I agree with you, I think it's the physicians that are also having difficulties sorting through what they need to do and what should be done. So I'll give you just you know, there are three kind of major people talking about this and trying to give recommendations, the American Cancer Society is one of them. And then a group of specialists called our organization called the nccn, which you and I known as the National Comprehensive Cancer network. And then the US Task Force came in a few years ago after a study rendered by the government and gave other recommendations. So there really are these three groups giving three kinds of varying recommendations and then our societies like you guys, as breast surgeons, or us as radiologists from the American College of Radiology, our organizations are kind of getting behind one or the other these camps. So the problem, of course, is that there are these varying, you know, opinions, and and these opinions have left a lot of problems. So, I feel personally as a radiologist, diagnostic radiologists, who's You know, I'm really trying to find cancer and the important thing is not just finding it, but also curing it and letting the woman live a normal life, we have to give the women the best chance. And so the American College of Radiology kind of sides on the on, and early detection of the younger patient and working our way through the entire age group. So we feel that the woman kind of old school should have a screening mammogram around the age of 35. And then from 40 on should have yearly mammograms. So this is kind of the American College of Radiology and the American Cancer Society are all kind of in agreement on that. I would say the nccn guidelines We're also similar. And and those guidelines continue to say, you know, continue to screen women, although there is some variation as women get older as to whether or not they should be annual or bi annual. But I think that the real thing now is becoming, you know, what, what is going on with stratification of risk stratification and trying to understand each woman as an individual. And that's really the discussion that you and I would take a long time to discuss. But really, that's what's going on is okay, after we sit down, and we talk to each other, and we say, Okay, I'm a woman who has, you know, a family history of breast cancer, and I have other things in my background that could put me at higher risk, then we probably need to start putting people in buckets and saying, you need screening mammogram on a yearly basis for a longer period of time than perhaps the woman who has no risks and has a fatty breast pattern, and all these things. So this is why there's so much confusion, because there's a lot of data and the data keeps coming at us. And and it keeps changing, and it will continue to change. But I think as a woman, learning about yourself and trying to understand some of these risks is what's important. Absolutely.

Unknown Speaker  6:08  
Thank you so much. The American Society of breast surgeons position statement is beginning screening mammography at age 40. And then annually thereafter, with no specific upper age limit. And you mentioned starting at age 35, with a baseline mammogram. So I just want the listeners to understand that one of the values of a baseline mammogram and then Dr. Hicks, correct me if I'm wrong, is really having something to compare to when you begin your screening mammography at 40. So that doesn't mean baseline at 35. And then every year, or even every other year, I try to explain to ladies in the office that the value of any imaging study, mammography, CT scans, MRIs, anything is really in comparison to old ones, because of course, change over time, gives us a lot of clues to diagnosis, right, new things are viewed sometimes with suspicion and changing things can be viewed with suspicion. So I do think that's valuable to have a baseline at 35. Is that why you the American College of Radiology, or your group recommends it

Unknown Speaker  7:35  
exactly. And I think, you know, there are a lot of new things coming down down the pike pretty fast. And so one of the things that's coming is that we actually UT using artificial intelligence, I'll use that word, it's really neural networks. But just using artificial intelligence, we've learned through feeding computers, lots of data. Now, we've learned that that mammogram contains a lot of information. So just the mammogram in and of itself, we now know that we can actually do risk stratification off just the mammogram. So you can envision a woman at 35 can start to get a feel for her real risks of developing breast cancer just based on the American so the mammogram is very important in that sets the kind of sets the balance of what's going to happen. And as you stated, it's so important for us as radiologists, we now start at the age of 40. Seeing you every year, we look for change. But we also now can start to put you into certain risk categories that will help all of us choose methodologies for for looking at your breast going forward. And again, as you probably as we all have learned over many, many years, breast density matters. And so this also gives us an idea right off the bat at a very young age, how dense the breast patients pattern is going to be. And that's going to be a very important thing going forward as as she goes through her life.

Unknown Speaker  9:01  
Yes, I definitely want to get to breast density more, but you mentioned risk stratified screening, which is definitely, really, I want to say an up and coming sort of idea, which is kind of crazy because it really lags in the rest of breast medicine, which has really over the last 10 to 15 years become extremely personalized, right. So our cancer treatments are so individualized compared to you know, the early 2000s. And that's sort of the mantra in cancer care whether it's choosing chemo therapies, whether it's choosing various things. It's very individualized, we talk about tumor DNA, but really, the screening realm has kind of lagged behind it where it's been a one size fits all really forever. And we're now just starting to get information out there that, like you say, maybe not everybody has the same breasts and doesn't have the same risk factor. So we should really treat screening very differently. And then one of those factors that isn't often talked about, and women can be surprised that they have it is breast density. So what else can you tell us about breast density?

Unknown Speaker  10:25  
I mean, I'll just step back a second and kind of discuss what you had talked about. I mean, we are running behind and I think radiologists have to take some responsibility for that. I think you can remember, back it wasn't that many years ago, when as a radiologist in Michigan, I came up and said to a group of physicians in a tumor board that I wanted to start, you know, putting risk data on the actual report for the patient so the patient could see it. And they were like, Oh, no, we don't want to do that. We're not sure what we're going to do with that data. And I'm like, well, we have to start talking about it. So I think the problem has been, there's been not a lot of communication around the data that was available. And the data that was available is really based on some of the older techniques that you and I know, are Gale scores, or tire kusik scores, which are computer based programs that are just asking you some basic questions, but they really didn't get into the meat of what was happening. So again, we're learning a lot right now, around a lot of the things that we can use to help women stratify that. So that's really important for us. And I think that's going to really change things. And the density issue is really one around what technique is so so if we looked at breast density, it's really cut up into four pieces. So we have women that have really fatty breast and fatty breast when you X ray, a fatty breast, you can see right through it, it's like looking through a window pane, you can see right through it. So if a cancer comes up, it's like a fly on the window, you can see it, there's a black fly on a white wind, or on a clear window, there it is, there's the cancer curtain. Really easy. Now as the weather changes, and it starts to rain a little bit, it gets harder. So that's like a woman who has scattered breast so it's raining a little it gets a little harder to see outside. And it's a little bit harder for me to find that fly on the window, because there's getting some water on the window and it's starting to get a little blurry. And and that's scattered breast tissue, as it gets more rain or perhaps turns to snow, we start to get in with this pattern where it's heterogeneously dense. So there's more and more density in the breast. And it's getting harder and harder to see not only the fly, which is black, but on our on our mammograms that cancer is white, and the density is white. So white on white doesn't work very well. So it's like looking for a needle in a snowstorm or or white thing in a snowstorm. It's hard to find. So that's heterogeneously dense. And then there's extremely dense patients. And they have breasts that are very much almost like cement. So they're white, so they're totally white. And we're trying to look for a white cancer inside this totally white process and is very, very hard. So the density matters in that it, it really restricts what we're able to tell a woman on her mammogram. So women walk into your center, they have mammograms and 25% of them might have dense breasts, which is about the right number 20%. They have done this extremely dense breast pattern. And they walk out of our centers. And we say there's no cancer, but we really don't know that for sure. And we miss we know that we're missing about 50% of those cancers, because we have other technologies that can see through that density and find those cancers. So that's important for those women to know that. Absolutely.

Unknown Speaker  13:23  
And I always tell ladies in the office that having dense breasts is like looking for a white fluffy cat and a blizzard. I mean, it's just difficult and hard to do. And you almost can't do it. By but density, like you say is really important. And it's actually an independent risk factor for the development of breast cancer, which really, again, has just sort of come to be talked about in the last couple of years. In fact, it wasn't until at least in Michigan, the the state government passed a law that said women had to be notified of their breast density, right every year on their mammogram so that they could have that information and make additional choices. I think many women would be quite surprised to know that, you know, 10, maybe even 15% of breast cancers are not picked up on a mammogram. And that's not an insignificant number,

Unknown Speaker  14:23  
that number rises as the density rises. So it could be 10 to 15% in a scattered patient. But as you get up into the extremely dense breasted patients, we are missing many more cancers than that. So it gets up in the 30 to 40%. Miss rate. And that's not because the cancer is there. And it's just that we can't see it. It's actually there but we can't see it. And there's no way for us to get better at that. It's a technology problem. Exactly.

Unknown Speaker  14:48  
It's really difficult. So what are some technologies that we have besides mammography that can help us advance screening, particularly in dense breasted women or for those who are at elevated risk for other reasons

Unknown Speaker  15:04  
will again, that's another area where we've made a lot of progress. So just like in the treatment side, we've made a lot of progress on the diagnostic side at improving imaging. So today, about 60, to 70% of mammography done in the United States is done with 3d or tomosynthesis. That helps in that we're slicing the breast into many different slices and, and it can be up to like 60 slices per per image or view. So those slices allow us to see inside the breast much more clearly than just a general shot through the breast. So we get these slices that allow us to see internally in the breast, so that's improved our detection rate by about one cancer per 1000, we find more than we did without it. So that's helped us a little bit, some, and then whole breast imaging, or ultrasound, whole breast ultrasound, where we scan the entire breast. And we do both breasts as a screening technique. So whole breast screening ultrasound has come along and is is being used more and more because that combined with total census adds another one or two cancers per 1000 that we can find. So we are improving with both the technology. And with the additional supplemental imaging. We also have brought on new technologies, something called contrast enhancement monography, which is basically injecting contrast, much like we do with cat scanning. And then we're able to use that contrast to look for areas in the breast that have increased blood flow. And cancers love to recruit blood vessels because they love to grow. And so as they grow, they recruit all these blood vessels, and they actually allow us to see them, which is nice, because we can see the contrast enhanced those areas where there's more blood. So that's a really, really good technique, it's really inexpensive to do, it does involve an IV contrast, but it's a really, really special technique that we're using more and more here at our centers. And then last but not least, well, there are several others, there's a nuclear medicine test that's much like that, where we inject a particle into your into your vein, and then we watch that particle, it also is going to go to areas where there's increased blood flow or accumulate, it accumulates, that that media that we're injecting into the breast and we use, we use radiation to actually see it coming out of the breast. So this is a different technique, nuclear medicine technique. And then last but not least, is probably my favorite or our favorite here at regional medical imaging is screening breast MRI. And screening breast MRI is not a new technique, meaning breast MRI has been around a long time. But the screening part of it is what's important is what we are trying to change and that is to use the actual MRI for screening purposes rather than diagnostic purposes. And we're doing that with shorter scan times where we can actually get more women through faster and they can, they could not have to be in the scanner as long but we get as much information out and we can find those cancers. And screening breast MRI actually finds breast cancer about twice the rate as mammography and ultrasound combined. So it is amazing technology and really, really, really great.

Unknown Speaker  18:11  
It absolutely is, you know, I am a big fan of screening breast MRI. And if I could brag about you, to the listeners that Dr. Hicks and regional medical imaging were the very first people in the entire country, possibly in the world, except maybe a group from Germany, who has been looking at this truncated or shortened form of breast MRI, just for the purposes of screening, not diagnostic, which is you have a problem. And we're investigating it. And that's why we're doing the breast MRI, we're just talking about, hey, I've got really dense breasts, I'm at elevated risk, and you want to get a breast MRI. And so this special screening MRI is really not offered anywhere, to my knowledge, at least in the state of Michigan except for at your centers. And I'm not even sure where else in the country it's being offered.

Unknown Speaker  19:20  
Yes. So we are working a lot on a national level to bring it on board and meaning there are a lot of radiologists working at a lot of practices trying to get this up and running in their centers. One of the problems they're running into is cost. So you know they how to reimburse This is still a question but you know, one of the beauties of being independently owned and operated is our abilities to kind of control costs and and make decisions about that. And so, you know, we are able to do this for $395 which is so much cheaper than anywhere else in that and that isn't because we cut corners. It's just because we have the abilities to do that under the under the cost structures that we have and that is a really reasonable rate. For women, so that's a really good opportunity that we've been trying to work on for many, many years about the cost issue,

Unknown Speaker  20:06  
right? And just so the listeners know, I mean, let's round it to 400. That is a lot of money. But if you were to get a breast MRI and your insurance were to cover it, and then you looked at the EOB, that came in the mail that said, this is not a bill. I mean, it might say, upwards of near $4,000 for, you know, a hospital based MRI or something, is that correct?

Unknown Speaker  20:32  
That is correct. And that's the problem. So that's why there's so much, you know, kind of pushed back on breast MRI, even at a screening rate, where they could maybe do four of them an hour, you still have this question of what's it going to cost to do that. And if we did that for an entire nation of women, and we didn't have to do the entire nation, but again, if we could risk stratify and put the women that need MRI into a bucket and do that, so let's say it's, you know, 30%, or 40% of the women, if we had to do that, what would that cost the nation? And so that's the real question around it. It's an unbelievable resource, but it's really something that we've got to figure out.

Unknown Speaker  21:08  
Absolutely. And lastly, for the listeners, I want to explain just the difference between an anatomic study and a functional study, right? So screening, or MMR, graphy, and ultrasound, tell you about the size and shape of something that you see. But the contrast enhancement mammography, breast MRI, molecular breast imaging, those not only are anatomic studies, but they are what we call functional studies, as well, because they can tell you what's happening on a cellular level. And that's why they're basically better at detecting breast cancer. Is that a good way to describe it?

Unknown Speaker  21:54  
It is and again, if you just think of it as one is just a picture of what's there, and the other is actually looking at what's happening inside that picture. So what's what's moving what's what's changing what's different. And that's really the beauty of those other techniques contrast enhanced mammogram and breast MRI is they allow us those additional data sets that are so valuable to us in finding breast cancer.

Unknown Speaker  22:21  
Exactly. Well, if a woman feels that she is at increased risk, or maybe doesn't even know her risk. What advice would you have for her in discussing with her primary care doctor or health care provider who's going to be ordering her mammogram are discussing breast imaging with her?

Unknown Speaker  22:46  
Well, I think the first thing you should do is make sure you do engage whoever's caring for you and engage them more fully. Perhaps that has happened in the past. And I think that means you need to sit down and say, you know, I really want to talk about my risk and what what what my risks are. And I will just preempt that by saying, you know, you can use your iPhone and you can, a simple test is something called Gale score. So you could just Google Gail g AIL and you could Google Gale score, and you can go sit down and in three minutes, you can kind of get a really, really high level, look at kind of your risk. If that gales working back at greater than 20%, you need to sit down and have a serious conversation about what's going on with your physician. And you really need to discuss that in a really in depth conversation in sometimes I say, you know, maybe you need to move off and talk with other people that perhaps are specialists in these fields like Dr. Gold or other people who perhaps talk about genetics. And, you know, there are some there are specialists who've talked to you about genetics. So there's so much value in all of this discussion. And there are so many new things that we can do to help genetic testings, all of these newer techniques for imaging, you know, all of these things that we can help you now to find that cancer if you're a high risk patient or a patient that's at the top of that, that normal range.

Unknown Speaker  24:15  
Absolutely, this has been such outstanding information. I'm sure the listeners will get a lot out of it. So I really, really, really appreciate you taking the time to spend with us today. I just want to remind ladies that we feel a baseline mammogram at age 35 is a reasonable start. And we begin annual screening mammography at age 40 and then generally every year thereafter. And we talked a lot about risk stratified screening. So the first step is to know your risk and the second is to discuss the available Different imaging modalities for any particular individual's type of breast, you know, risk goes beyond just my mom had breast cancer or my grandma or my aunt. I hope everybody's learned that knowing your breast density is super important to try and determine risk and what particular imaging studies that you have. Well, Dr. Hicks, you and I could talk about, you know, all day all night and into the next week about other aspects of breast imaging. So, hopefully you'll be willing to join us again in the future for other topics. That would be great.

Unknown Speaker  25:44  
Appreciate your having me.

Unknown Speaker  25:46  
Yes, I just want to say also that for the listeners, the Dr. Hicks website, rmipc.net - an excellent resource for all of this information, as is our website. Thank you so much.