Dr. Rachel Brem: Breakthrough Women in Science & Medicine

- I had my screening mammogram at the beginning of 2022.

I received an "all clear" every time, and I found my breast cancer, a small dimple, in November of 2022.

So less than a year.

- The best way to find early curable breast cancer is to get the screening you need.

But just because you have a normal mammogram is no guarantee that you don't have breast cancer.

And that's why it's very important for women with dense breasts to know that mammography is not enough.

- They should have known about the dense breast issue.

They should have advised me better.

I wish somebody would've raised their hand and said, we can't see.

We need additional tests.

I felt betrayed.

I don't think any woman should have to go through that.

You shouldn't have to fight your doctors to save your life when you're dealing with breast cancer it's scary.

I mean, you really just wanna crawl up in a ball and pretend like it didn't happen.

But you have to have this state of mind to demand the right test to save your life and that needs to change.

– Major funding for this program was provided by: - BC Ruckus was founded to educate women with dense breasts about the failure of mammography, including 3D tomosynthesis to detect tumors and advocate for equitable access to supplemental screening.

- To learn more about breast density, access helpful tools, and explore additional breast cancer screening options, visit my density matters.org.

Early detection saves lives.

- Connecticut was the first state to standardize breast density through the mammography report.

Join us to learn more about our national breast density reporting law and your role in exposing the best kept secret.

– Additional support provided by the following: - In November of 2022, you know, I had had a mammogram earlier in the year.

I noticed a slight dimple on my left hand side and I decided I need to go in for a diagnostic mammogram.

They took biopsies 'cause they saw something, and 10 days later the report came back that I had a slower growing tumor on my left hand side.

It was very frustrating when I was diagnosed with the breast cancer on my left hand side, and I requested additional testing on the right hand side to make sure that there was no breast cancer there.

I was really met with a lot of resistance.

I think that's the thing that's most troubling to me because why?

What, what was the cost of ruling it out?

Why was there so much resistance?

It was almost like an arrogance.

Well, we did the, the test we're supposed to do and there's nothing there.

And now you're being a difficult patient.

Why don't, why wouldn't you just go away?

And you know, of course I didn't wanna be right.

When I found out that there was a bigger tumor on my right hand side, I was devastated.

I, I was so hopeful, right, that the oncologist was correct and that I was totally hysterical, demanding the additional screening.

But then when I was validated, it was, you know, it made me more angry.

Fact of the matter is given the size of the tumors, it was clearly there, not only at the beginning of 2022, but my doctors have said at least five years beforehand.

- Mammography is a great test.

If you have a screening mammogram, we will find breast cancers in about five of every thousand women who has a screening mammogram.

Unfortunately, for women with dense breasts, we don't perform quite as well.

So we might only find three or four cancers per thousand in women who have dense breasts.

- The normal breast is made up of a combination of fat and dense glandular tissue.

And the amount of that dense glandular tissue can vary depending on various factors.

For example, younger women very frequently have dense tissue, and as a woman ages that tissue density decreases.

I want to be clear that mammography is part of this solution for early detection of breast cancer in all cases, but for certain individuals and mammography alone may fail to detect certain breast cancers.

- So mammograms will miss breast cancers in dense breast tissue.

They're gonna find about 50 to 70% of breast cancers on a mammogram, but some will be missed.

- Here's a mammogram of a woman with dense breasts.

You can see all this white tissue and there's nothing here that is super concerning.

But you might be surprised if I were to tell you that in the upper, outer portion of this right breast, there's a breast cancer lurking there that we can't see on this mammogram.

But I'm gonna show you the ultrasound.

So despite our having a negative mammogram six days earlier, we see a hypoechoic, meaning a dark mass that is taller than it is wide, that has irregular margins that go in and out and in and out.

And it's blocking the sound waves so the waves can't get through here.

This is a big cancer that's sitting in there that was not seen on the mammogram.

So this ultrasound finds a cancer despite a normal mammogram in a woman with dense breast.

- We're fighting a lot of things in order to make change.

Insurance companies, medical systems, standard of care, shortages of equipment, but when I see people like Dr. Rachel Brim, I think there's hope.

I think we can make the change that's necessary so that women can find their breast cancer earlier and have the best chance of saving their lives.

- She is a woman with tireless energy.

She's always thinking of how can we do this better?

How can we make some advancement?

What can we do to think out of the box so that women will not die from breast cancer.

When she puts her mind to something, things happen.

She is the greatest advocate for women at increased risk for breast cancer.

And of course for those that she diagnosis with breast cancer.

- My first experience with breast cancer was at the age of 12 when I was told that my mother, who was 33 at the time, was diagnosed with breast cancer.

The good news is that she lived 44 years, got to raise us, see grandchildren, and even great-grandchildren.

It was my first exposure to the real impact, to the profound impact of early detection.

I had a mother because of early detection, but I was committed and I knew that that's what I wanted to do.

So that, you know, was an inspiration and a motivation early on in life.

So no surprise with the family history, like I have my mother, my aunt having breast and ovarian cancer.

In 1996, I found out that I was BRCA1 positive as well.

And so I had scheduled prophylactic mastectomies and oophorectomy - ovaries out because I wanted to change the narrative of my family.

But in that time, I was also charged with finding a new ultrasound unit for the practice, and I told all the vendors to bring it in that evening.

And after a day of seeing patients, I scanned myself.

So that evening I found which ultrasound unit I wanted to use, but I also found my own breast cancer.

And although I had been scheduled for prophylactic surgery, this now switched to cancer surgery because I had found this small early ultrasound detected breast cancer.

Well, for many things there's a silver lining, and so the passion to really impact the world for breast cancer became even stronger.

Now, I also knew that because I felt so lucky that I had the information that I needed when I was diagnosed, that I had a reason to go beyond medicine and really educate other women about what they need to do when they're diagnosed with breast cancer.

- Rachel Bram is truly an inspirational human.

She has, both the work she's done from an educational standpoint in radiology, and indeed her research and her leadership in the community.

And I think in particular of the Brem Foundation, which has provided help and support and information to vast numbers of women.

- The only way a woman could know if she has dense breast tissue is by a mammogram.

You can be perky dense, you can be saggy dense, you can't tell by feeling.

But in all comers, mammogram finds 85% of breast cancer in women with dense breast.

Up to 60% of breast cancers can be not seen because of this masking effect.

It's like looking for a cloud in the cloud filled sky.

If the sky is blue, you have no trouble seeing a specific cloud, if the sky is white with clouds, where does one cloud start and the next one end, you don't know.

And that's really important to know because if you do have dense breast tissue, a mammogram is not enough.

- Not only is it hard to find breast cancers in women who have dense breasts, but also women who have dense breasts are at an increased risk for developing breast cancer.

The women with the densest breasts, if you compare them to the women with the fattiest breasts, their chances of having a cancer may be as much as four to six times as high.

- And this patient, this was her MRI, so extremely dense.

What you see, all of this dark tissue here on MRI, that's her dense tissue.

It's sort of the opposite of mammography.

The white areas here are her fatty tissue.

She's almost completely dense.

Almost everything she has is that dense tissue and hiding in that dense tissue.

Once we gave her the contrast in mammography in MRI rather, that's her cancer on MRI, that was not at all visible on her mammogram and very obviously visible on MRI.

And the reason that she had MRI was because she had very, very dense breast tissue that was making her risk score for lifetime risk for developing cancer greater than 20%.

You know, we're looking at something like if you measured it, you're talking about being able to see something that's eight millimeters on MRI.

You know, you see how dense that tissue is it might need to be twice as big as that before it would show up on mammography.

But on on MRI, it shows up, you know when it's still less than a centimeter in size.

- So the mandate that the government has implemented recently basically requires that every radiology practice that performs mammography informs each patient that has a mammogram of what their breast density is.

When you are in the "C" or "D" category, it means you'll be told when you go to have your mammogram that you have "dense" breast tissue.

Every state will be giving you that information, but I think it will take a while for every state that hasn't had the time that we've had in New York to really get their primary care physicians / healthcare providers really up to speed on this.

The American College of Radiology has implemented and created the BI-RADS Atlas, and that is required classification for breast density for all radiologists that interpret mammograms.

There are four categories: A is fatty tissue, B is scattered, some fatty and some fibro glandular tissue.

C is heterogeneity dense.

D is extremely dense.

So most women sit either in the scattered, that's B or the heterogeneity dense.

Together they can make as much as 80% of the population of patients that we will screen every day with a mammogram.

- So when it comes to dense breasts, we actually don't have any guidelines about which testing women should have.

Organizations like the American College of Radiology have recommendations, but there are no official government guidelines saying which test women should have.

And as a result, insurance companies are not obligated to pay for any kind of supplemental screening.

- It's important to know that many practices don't routinely recommend additional screening for women with dense breasts.

And that's why it's so important that every woman know what her breast density is so she can insist on the additional screening she deserves.

So if your average risk and you don't have dense breast tissue, a mammogram is enough.

If you do have dense breast tissue and that's your only additional risk factor, then screening breast ultrasound can find double the number of cancers.

And MRI can find even more than that.

Now, the MRI is the highest sensitivity, the best way to find breast cancer.

And if you are at an increased risk of breast cancer, greater than 20% lifetime risk than you should be having a mammogram and an MRI every year.

So there are other modalities that can find these cancers that are hidden in dense breast tissue, including molecular breast imaging, which looks at how the tissue functions, not just how it looks.

And it requires an injection of a low dose of a radioactive tracer.

- In the United States about one in every eight women is gonna develop breast cancer in her lifetime.

But I think the important thing to understand is that your risk is not average.

Your risk is personal.

And the screening tests that you need are dependent on what your personal risk is for developing breast cancer.

- If you have a first degree relative who had breast cancer, you should start screening five to 10 years earlier than the age that your first degree relative had breast cancer.

So those recommendations are for women at average risk of breast cancer, but we have to start even younger in women with a family history or in high risk groups.

So that would be Ashkenazi Jewish Americans where the BRCA gene is prevalent at 10 times higher rate.

So one in 40 Ashkenazi Jews have a gene that is associated with a markedly increased risk of breast cancer.

And black Americans have a much higher death rate, are at higher risk and get younger breast cancer.

So we have to look at every population individually and really give them the best recommendation that we can.

We expect our doctors to know everything about our health, but that's asking a lot of primary care physicians.

And that's why I and the Brem Foundation and others feel that it is our responsibility to educate and empower women so they know what they need for themselves.

Yes, it would be best if every healthcare provider knew about breast density, about the need for supplemental screening, but they don't.

- You know, I did what the note said.

I went in and talked to my doctor and said, do I need something else other than what I'm getting?

And my doctor said, you have heterogeneously dense breasts, you have no family history.

You eat well.

So you don't have a lot of risk factors.

And for you, the supplemental screening that you need is 3D tomosynthesis.

That is the extra screening that you should be getting.

- 3D mammography is not supplemental screening for women with dense breast tissue.

It might work marginally better than 2D mammography, but it is insufficient to find those hidden cancers.

It's still white breast tissue and white breast cancer still has the masking effect.

Additional screening is needed.

So if you are told that you have dense breast tissue and are not offered at least screening ultrasound, ask for it, raise your voice, insist on it.

And the final big obstacle is insurance.

So many of these will not be covered by insurance.

And if that is the case that this is one of the few times that no does not mean no.

You need to call your insurance company, advocate for yourself and make sure that you have access to these lifesaving tests.

- So it's time for women to become involved.

There's legislation pending in Congress to make supplemental screening mandatory to make it be a covered service for everybody.

It's time to talk to our representatives in Congress, in the Senate, in our state legislatures, and let them know how we feel.

- You know, it's very important for women to know that a screening mammogram is free, no copay, no deductible, even on January 1st based on the Affordable Care Act.

However, diagnostic mammography is not the same, and supplemental screening is not covered under that.

The Find It Early Act is an act that is a bipartisan act being supported by both parties.

That will make all mammography, all breast imaging, no copay and no deductible.

So not only women of means can get these supplemental lifesaving screenings, but underserved women or women who simply can't afford it don't have to decide between dinner on the table and lifesaving tests to find early curable breast cancer.

It will cover all breast imaging with no copay and no deductible.

As of now, the Find It Early Act has not passed through Congress.

And we hope that in future congresses that this law will indeed pass.

- Access to supplemental screening in the United States currently varies widely.

Individuals who are asking and seeking out additional imaging, including ultrasound and MRI may be told that that is simply not an option for them.

- Breast cancer is not an equal opportunity disease either in the way it presents in the survival, the treatment, or the availability of supplemental screening.

So black women die 40% more frequently at a higher rate than white women of breast cancer, even when diagnosed at the same stage.

And we are so lucky that we are focusing on healthcare disparities now, but as we do, we have to make sure that in underserved communities, in communities of color, in communities that are primarily minorities, that we have to make sure that when we do offer healthcare, when we do increase the offering of mammography, that it is the highest quality mammography and that supplemental screening is available as well.

- In 2024, the US Preventive Services Task Force guidelines changed.

Previously the guidelines had said to start at the age of 50 and have mammograms every other year.

As of this year, the task force is recommending start at the age of 40 and come every other year.

In some ways, those guidelines are an improvement.

I wish they had gone farther.

What the science shows is that the guidelines that save the most lives are, start at 40 and have screening every year.

And in fact, those guidelines will reduce your risk of dying from breast cancer by about 40%.

- Ready?

Yes, yes - I understand that I'm currently cancer free.

So far so good.

I get surveillance every six months.

It's either a breast MRI alternated with a tomosynthesis exam.

The tomosynthesis exams I think are pretty worthless.

So I actually go outta state to get a contrast.

Enhance mammography, which appears to have some additional benefits for detecting cancer early.

So a lot of people wonder why I am fighting this fight right now, trying to get expanded insurance coverage in our state and trying to get other women educated on the dense breast issue.

I think back to where I was in the room with that oncologist and I was fighting to get the test for the second breast cancer screening, and I still have PTSD from that day.

I still wake up in the middle of the night in a cold sweat.

I cry a lot because of that time.

And I worry about other women.

I worry that you know, they wouldn't have had a, the tenacity, the resources, just the dogged determination, right?

To demand the additional screening that they need to save their lives.

And that's why I'm doing this.

- The United States now has a 50 state mandate that a woman should be told her breast density at the time she has a mammogram.

It's less well known that that has its origins of Dr. Nancy Capello from Connecticut.

She had a mammogram, she was given the all clear, and then three months later she had another image and was told that she had a inoperable breast cancer.

She reacted by fighting to understand about breast density and then got a law passed in Connecticut.

And from that state by state to the point where now the whole of the United States has breast density legislation for women having had mammograms.

- This movement about breast density is to make every woman aware that mammograms are insufficient if you have dense breast tissue.

Whether it's Nancy Capella, who was the impetus to start this campaign, or Sheila Mikhail who is taking on that campaign now, or women like myself who had dense breast tissue and had a negative mammogram with an ultrasound that showed breast cancer.

As both the physician and the patient, we have to empower women with this information.

Breast cancer is not a death sentence, and you have to really understand that early breast cancer is largely curable with 95% plus five year survival.

- Every single woman needs to educate herself about whether or not she has dense breaths and needs to walk into the conversations with her doctor, armed with that information and prepared to have a conversation to ask for the supplemental screening that she needs.

- If you have a mammogram that is given the all clear, but you are told that your breasts are dense, do not accept that at face value.

Seek additional images, seek different kinds of images.

It's important to you and to your family that you do that.

- We need more Rachel Brems in order to make this happen.

We need more women advocating for other women.

- Women in STEM is critical because we bring new perspectives.

We bring new needs.

So many clinical trials even we're largely men.

And now we know that we can't impact the life of women without the women perspective from science, the women perspective on data interpretation and on impacting the health and the overall health and outcome of women.

So we bring a completely new perspective, and that perspective is absolutely critical to achieve the best outcomes for everybody.

– Major funding for this program was provided by: - BC Ruckus was founded to educate women with dense breasts about the failure of mammography, including 3D tomosynthesis to detect tumors and advocate for equitable access to supplemental screening.

- To learn more about breast density, access helpful tools, and explore additional breast cancer screening options, visit my density matters.org.

Early detection saves lives.

- Connecticut was the first state to standardize breast density through the mammography report.

Join us to learn more about our national breast density reporting law and your role in exposing the best kept secret - Additional support provided by the following: