WEBVTT - What Are The Chances 0:00:03.200 --> 0:00:09.959 Hey, everybody, welcome to a special episode of Amy and 0:00:10.119 --> 0:00:12.680 TJ Robots. Sitting here next to me. A lot of 0:00:12.720 --> 0:00:15.040 people have been following along with us the past. I 0:00:15.040 --> 0:00:17.320 guess a couple of weeks we did a show talking 0:00:17.360 --> 0:00:20.480 about on one of the episodes talking about you not 0:00:21.400 --> 0:00:24.880 making an appointment and being over a year, a year, 0:00:25.160 --> 0:00:28.320 a year and a half a half since you win 0:00:28.480 --> 0:00:30.360 for blood work that you were supposed to have. Do 0:00:30.440 --> 0:00:32.319 I have that right as a Breastkansas riber. 0:00:32.400 --> 0:00:35.080 I have been doing it every six months or so 0:00:35.520 --> 0:00:37.600 up until well, you know. 0:00:38.120 --> 0:00:42.120 Yes, everything hit the fan. But we do update people 0:00:42.159 --> 0:00:45.440 recently that you have made the appointment, are going to 0:00:45.440 --> 0:00:48.479 get your blood work done very soon. And that appointment 0:00:48.600 --> 0:00:51.120 is with someone you speak so highly up all the time, 0:00:51.159 --> 0:00:51.720 Doctor Ritz. 0:00:51.920 --> 0:00:54.800 Yes, doctor Ruth Ratz, and she is actually in the 0:00:54.880 --> 0:00:57.400 studio with us. She is my oncologist. She has been 0:00:57.440 --> 0:01:01.760 with me from the very beginning since I was oh yes, 0:01:01.840 --> 0:01:03.920 a young pop of forty when I got my breast 0:01:03.960 --> 0:01:06.200 cancer diagnosis. But doctor Ortz has been on the journey 0:01:06.240 --> 0:01:07.920 with me every step of the way. And so first 0:01:07.920 --> 0:01:10.640 of all, I'm just gonna apologize for having left so 0:01:10.720 --> 0:01:13.440 much time and space between us over the past year 0:01:13.480 --> 0:01:15.840 and a half. But it's so good to see you 0:01:15.880 --> 0:01:17.559 and we're so happy to have you in the studio 0:01:17.680 --> 0:01:18.000 with us. 0:01:18.000 --> 0:01:21.120 So welcome. I'm happy to be here. I'm delighted to 0:01:21.120 --> 0:01:24.440 be here with both of you and Amy. You know, 0:01:24.680 --> 0:01:28.399 I stalk you, so even though I haven't seen you 0:01:28.440 --> 0:01:32.000 in person, I know you've been okay. Oh, and I 0:01:32.040 --> 0:01:34.520 see you training, I see you out there running. I 0:01:34.560 --> 0:01:37.640 know you're healthy, and I know that you take really 0:01:37.680 --> 0:01:38.640 good care of yourself. 0:01:38.959 --> 0:01:39.280 Thank you. 0:01:39.319 --> 0:01:41.479 So we'll update everything see you okay. 0:01:41.560 --> 0:01:43.800 Yeah, and a couple and a couple of weeks, we've 0:01:43.840 --> 0:01:46.200 got the appointment, but we asked you to come into 0:01:46.240 --> 0:01:49.480 the studio because there's been a big headline this week 0:01:49.560 --> 0:01:53.200 with actress Olivia Munn. She's forty three years old. She 0:01:53.680 --> 0:01:57.080 let everyone know that she has just been through ten 0:01:57.120 --> 0:02:01.040 months of treatment for breast cancer. That, of course, is 0:02:01.080 --> 0:02:03.960 always a big announcement when there's someone famous who can 0:02:04.080 --> 0:02:08.040 bring awareness to the cause. But it's a unique story 0:02:08.160 --> 0:02:11.280 because she's talking about how she found her cancer. She 0:02:11.400 --> 0:02:14.760 said she had a clearant mammogram. She said that she 0:02:15.639 --> 0:02:17.880 didn't have any of the markers for genetic testing that 0:02:17.919 --> 0:02:21.080 would make her a candidate for potentially having breast cancer, 0:02:21.120 --> 0:02:24.000 but then she said her doctor two months later had 0:02:24.000 --> 0:02:27.560 her do a breast cancer risk assessment test, and that 0:02:27.680 --> 0:02:31.040 led to more tests, which led to her finding an 0:02:31.040 --> 0:02:35.960 aggressive form of breast cancer in both breasts. And I 0:02:36.080 --> 0:02:38.440 kind of thought I knew a lot about breast cancer 0:02:38.600 --> 0:02:40.919 throughout my journey, but even I was scratching my hat. 0:02:41.080 --> 0:02:45.240 A breast cancer risk assessment test. Please explain what that 0:02:45.560 --> 0:02:47.600 is and just put this into perspective for us. 0:02:47.720 --> 0:02:50.600 Yes, I think we were all very shocked to hear 0:02:50.639 --> 0:02:55.160 this story and it raises an important issue, particularly for 0:02:55.240 --> 0:02:58.640 young women who were diagnosed with breast cancer. Let me 0:02:58.720 --> 0:03:00.800 just back up and talk about the man. You know, 0:03:00.840 --> 0:03:05.000 we do want everyone to have mammogram screening, but as 0:03:05.040 --> 0:03:09.480 I always say, it's not one size fits all, and 0:03:09.840 --> 0:03:13.880 for many young women, the mammogram won't show early stage 0:03:13.880 --> 0:03:17.080 breast cancer because the breast tissue is very dense in 0:03:17.200 --> 0:03:20.600 young women and the mamogram doesn't show enough. So that's 0:03:20.600 --> 0:03:25.280 why it's really important for each individual to speak with 0:03:25.400 --> 0:03:29.880 her doctor about what are the other potential factors that 0:03:30.040 --> 0:03:34.120 could be contributing to a risk of breast cancer and 0:03:34.440 --> 0:03:38.320 do we need to change up or add something to 0:03:38.360 --> 0:03:42.960 the screening and surveillance. Now, the Breast Cancer Risk Assessment 0:03:43.000 --> 0:03:49.120 Tool could be helpful. It's a statistical model that was 0:03:49.240 --> 0:03:52.640 developed many years ago. We've had this, you know, for 0:03:52.720 --> 0:03:57.280 probably fifteen twenty years already, and it's a simple computer model. 0:03:57.320 --> 0:04:00.560 It's free. It's available online. You can click on a 0:04:00.600 --> 0:04:03.720 website and bring it up, and it asks a few 0:04:03.880 --> 0:04:09.200 basic questions about a woman's personal history. It's really developed 0:04:09.200 --> 0:04:11.200 for women. We know men can get breast cancer, we'll 0:04:11.200 --> 0:04:14.640 come to that later, but focusing on women, it is 0:04:14.840 --> 0:04:19.359 they ask about age, family history of breast cancer, focusing 0:04:19.440 --> 0:04:24.279 on close relations we call those first degree relatives, mother, sister, daughter, 0:04:25.520 --> 0:04:28.640 whether or not the person has had a prior biopsy 0:04:28.720 --> 0:04:32.520 of the breast that showed any atypical cells. And then 0:04:32.560 --> 0:04:36.080 some questions about reproductive history. How old you were when 0:04:36.120 --> 0:04:39.520 you had your first menstrual period, how if you've had pregnancies, 0:04:39.520 --> 0:04:42.040 how old you were at the time of that first pregnancy. 0:04:42.760 --> 0:04:47.160 And then there's a calculation that's made that gives an estimate. 0:04:47.240 --> 0:04:49.920 I mean it's not perfect, but an estimate. You know, 0:04:50.000 --> 0:04:52.320 what's your risk of getting breast cancer in the next 0:04:52.360 --> 0:04:55.960 five years? Or over your lifetime up to age ninety 0:04:56.720 --> 0:04:59.160 and compares that to the general population. 0:05:01.160 --> 0:05:05.560 I think that the test is what's throwing everybody right now. Okay, 0:05:05.200 --> 0:05:08.159 you tell people, tell women, go get a manogram, You 0:05:08.200 --> 0:05:09.800 tell them what age to do it, how often to 0:05:09.839 --> 0:05:13.480 do it, You go in, mamogram's clear and you should 0:05:13.480 --> 0:05:16.400 be in the clear. Now, why would you take the 0:05:16.440 --> 0:05:20.120 next step or why isn't everyone being told to take 0:05:20.279 --> 0:05:23.479 do a mammogram and go online and everybody do this 0:05:23.600 --> 0:05:24.480 risk assessment test. 0:05:24.640 --> 0:05:26.800 Yeah, that's sort of actually a great question. We have 0:05:26.960 --> 0:05:30.919 not made that recommendation. In this case, it did lead 0:05:31.120 --> 0:05:34.800 to a diagnosis of breast cancer. I think maybe the 0:05:34.880 --> 0:05:37.280 concern is that if everyone did it, there would be 0:05:37.400 --> 0:05:40.279 kind of like mass panic because a lot of people 0:05:40.440 --> 0:05:43.960 might have a slightly increased risk. I don't know how 0:05:44.080 --> 0:05:46.960 hurt test actually, you know what the numbers were or 0:05:46.960 --> 0:05:47.680 how it came out. 0:05:47.800 --> 0:05:49.279 So thirty seven actually was it? 0:05:49.279 --> 0:05:52.880 I have it right? Thirty seven lifetime risk. Yeah, so 0:05:52.960 --> 0:05:56.600 that is higher than the average American woman who has 0:05:56.640 --> 0:06:00.279 a twelve percent lifetime risk. So that was high enough 0:06:01.080 --> 0:06:04.520 that it triggered the extra testing by her doctor. So 0:06:04.600 --> 0:06:06.279 you know, as I was thinking about that. I mean, 0:06:06.360 --> 0:06:09.520 maybe you're right, TJ. Maybe more people should go online 0:06:10.520 --> 0:06:13.280 kind of get a rough idea where they fall out 0:06:13.320 --> 0:06:17.640 on that. But remember it's just a rough idea. So 0:06:18.600 --> 0:06:20.799 Olivia did the right thing. She took the next step 0:06:20.800 --> 0:06:22.640 and went to her doctor and said, what does this mean. 0:06:24.120 --> 0:06:26.800 This is also something that has been interesting to me 0:06:26.880 --> 0:06:29.520 because yeah, I had never even heard of this test was. 0:06:29.680 --> 0:06:31.560 We had to look it up and figure out what 0:06:31.640 --> 0:06:35.120 it was. But I think most people know my history 0:06:35.200 --> 0:06:38.560 that I had a mammogram at age forty because I 0:06:38.600 --> 0:06:40.680 had a work assignment, not even because I was going 0:06:40.680 --> 0:06:43.479 in there. Because at the time I was diagnosed, the 0:06:43.480 --> 0:06:46.880 recommendation was fifty, then it went to forty five, and 0:06:46.920 --> 0:06:49.479 now it's down to forty, which we're all applauding. I 0:06:49.520 --> 0:06:51.520 know you are as well. Anyone who works with breast 0:06:51.560 --> 0:06:55.360 cancer patients is saying, yes, forty years old. But I 0:06:55.480 --> 0:06:59.880 ended up getting a sonogram after the mammogram showed abnormal. 0:07:01.320 --> 0:07:03.760 If the sonogram is a better test than a mammogram, 0:07:03.839 --> 0:07:06.159 or at least maybe a clearer test for younger women 0:07:06.200 --> 0:07:10.360 who have potentially dense breast tissue, why wouldn't there always 0:07:10.360 --> 0:07:13.840 be a sonogram or maybe even a sonogram versus a mammogram. 0:07:14.280 --> 0:07:18.560 Well, I think you're right, Amy, And in my personal practice, 0:07:18.600 --> 0:07:21.760 when I see young women at risk for breast cancer, 0:07:21.800 --> 0:07:25.000 they haven't had breast cancer, but at risk, let's say, 0:07:25.040 --> 0:07:28.920 because of family history, or they had a concern about 0:07:28.960 --> 0:07:32.000 something and came in to be evaluated, we do always 0:07:32.040 --> 0:07:35.280 add the sonogram. Some people who are very young, I 0:07:35.360 --> 0:07:38.080 do the sonogram and I skip the mammogram because I 0:07:38.120 --> 0:07:40.000 know that mammogram's not going to show me a whole 0:07:40.000 --> 0:07:43.160 lot in someone who's very young, maybe in her thirties. 0:07:44.560 --> 0:07:51.160 So again, you know, those screening recommendations are that everybody 0:07:51.160 --> 0:07:53.040 should do the same thing, and I think we have 0:07:53.120 --> 0:07:57.920 to tailor our recommendations to the individual person. And this 0:07:58.080 --> 0:08:01.400 risk assessment test is some thing I run in the office. 0:08:01.840 --> 0:08:05.400 I do it, and I might share that information with 0:08:05.440 --> 0:08:07.440 my patient and say, look, your risk isn't as high 0:08:07.440 --> 0:08:10.600 as we thought, or maybe it's higher than we expected, 0:08:11.480 --> 0:08:14.040 or gee, we should do some genetic testing in you 0:08:14.160 --> 0:08:17.680 because of your family history. So you know, there are 0:08:17.720 --> 0:08:20.200 many factors we look at, and this should be one 0:08:20.200 --> 0:08:23.840 of those things that gets incorporated into risk assessment. Lots 0:08:23.840 --> 0:08:27.160 of gynecologists do it and I think that's what happened 0:08:27.160 --> 0:08:29.360 in this instance. Or doctor said, let's just run this 0:08:29.440 --> 0:08:31.760 on you and see how it comes out, like you 0:08:31.840 --> 0:08:32.720 don't know what it triggered. 0:08:32.720 --> 0:08:35.640 It's free, and why not Why wouldn't you do that? 0:08:35.679 --> 0:08:38.000 There's no argument to not do it correct. 0:08:38.120 --> 0:08:40.920 I mean, you know, I always say knowledge gives us power. 0:08:42.200 --> 0:08:45.600 The sonogram versus mammogram does one? Is there a difference 0:08:45.640 --> 0:08:48.880 in cost to the or or what insurance will cover, 0:08:49.400 --> 0:08:50.479 so neither. 0:08:50.280 --> 0:08:54.200 Of them are expensive tests. And but for whatever reason, 0:08:54.640 --> 0:08:59.680 the insurance companies and Medicare and whatever has set up 0:08:59.720 --> 0:09:02.720 this paradigm that you have to do the mammogram first. 0:09:03.080 --> 0:09:05.079 Huh before you can order the sonogram. 0:09:05.160 --> 0:09:05.400 Huh. 0:09:05.520 --> 0:09:09.720 Yep, it's kind of a crazy thing. I cannot understand it. 0:09:10.160 --> 0:09:11.600 Insurance generally cover both. 0:09:11.880 --> 0:09:14.200 Yeah, it will eventually get covered, but sometimes you have 0:09:14.240 --> 0:09:16.760 to go through the mammogram and then we can order 0:09:16.800 --> 0:09:21.880 the ultrasound and for our older patients. Actually, just this 0:09:21.960 --> 0:09:31.000 past year, Medicare changed their system so that we cannot 0:09:31.160 --> 0:09:33.440 order the mammogram and ultrasound to be done on the 0:09:33.480 --> 0:09:37.360 same day. The prus has to have the mammogram and 0:09:37.559 --> 0:09:40.200 then if we think the sonogram is indicated we order 0:09:40.200 --> 0:09:41.880 it and she has to go back a second time. 0:09:42.360 --> 0:09:46.200 It's it's absurd and look, I have shared the story before, 0:09:46.240 --> 0:09:49.040 but I haven't here on this podcast. I was outraged 0:09:49.080 --> 0:09:51.400 when I had the first mammogram and the Mamma Van 0:09:51.640 --> 0:09:55.000 in the middle of Times Square. They just saw something suspicious. 0:09:55.320 --> 0:09:58.640 There was no nothing specific to cancer. They just said, 0:09:58.640 --> 0:10:01.160 you know what, we'd like you to get another mammogram 0:10:01.200 --> 0:10:03.920 because something looks a little off. And so when I 0:10:03.960 --> 0:10:07.320 went to go make the follow up appointment at Nyu 0:10:07.400 --> 0:10:09.400 Lang Gone, I got a call the night before from 0:10:09.400 --> 0:10:11.880 my insurance company saying we are not going to cover this. 0:10:12.600 --> 0:10:15.000 And so NYU called me and said, you're going to 0:10:15.040 --> 0:10:16.880 have to give us your credit card if you want 0:10:16.880 --> 0:10:19.800 to keep the appointment for tomorrow. And I almost did 0:10:19.840 --> 0:10:22.000 not do it because I was annoyed A that I 0:10:22.080 --> 0:10:23.880 was going back for a second one and B that 0:10:23.960 --> 0:10:25.520 I was going to have to pay at least eight 0:10:25.640 --> 0:10:28.440 hundred dollars out of pocket. Eight hundred dollars to a 0:10:28.440 --> 0:10:30.920 lot of people is not even an option. That's their 0:10:30.960 --> 0:10:33.560 rent payment, that's food on their table. I was lucky 0:10:33.640 --> 0:10:35.720 enough to be able to afford it, but to think 0:10:35.760 --> 0:10:38.280 that insurance companies get involved in a way where they 0:10:38.280 --> 0:10:41.800 make life so much more difficult and potentially could could 0:10:41.840 --> 0:10:46.000 be costing women lives, time, money, etc. I know you, 0:10:46.040 --> 0:10:48.040 as a doctor have to be so frustrated by this. 0:10:48.400 --> 0:10:51.640 We are very frustrated by it. And you know that 0:10:51.720 --> 0:10:56.199 eight hundred dollars bill is probably including other costs than 0:10:56.440 --> 0:10:58.600 just the cost of doing the X ray, because we 0:10:58.679 --> 0:11:03.319 know that when we've done mass screening projects sending those 0:11:03.400 --> 0:11:07.439 vans out, for example, we can bring the cost down 0:11:07.600 --> 0:11:10.760 significantly and we don't want cost ever to be a 0:11:10.800 --> 0:11:14.079 barrier for women to get the right screening that they need, 0:11:15.000 --> 0:11:20.360 So that's really really important. It is very frustrating. And 0:11:20.400 --> 0:11:24.120 again in our younger patients in particular, people say, oh, well, 0:11:24.120 --> 0:11:26.719 breast cancer doesn't happen in people that age, but it 0:11:27.200 --> 0:11:30.360 sure does, you know, and you know that too all 0:11:30.400 --> 0:11:30.800 too well. 0:11:30.920 --> 0:11:32.760 The doctor oris with a living mon here help me. 0:11:32.800 --> 0:11:35.840 And again I'm familiar to a certain degree and to 0:11:35.840 --> 0:11:38.640 feel maybe familiar little more because of who I'm in 0:11:38.679 --> 0:11:41.640 love with here and the history of breast cancer. But 0:11:42.200 --> 0:11:46.040 the order someone's told to go get a mammogram, you 0:11:46.080 --> 0:11:51.280 get that mammogram. If it's clear, then there is no 0:11:51.480 --> 0:11:55.559 next step necessarily right, You're done until your next scheduled appointment. 0:11:55.559 --> 0:11:58.480 A living your month is saying the doctor. So the 0:11:58.520 --> 0:12:01.360 clear mammogram, but still we went ahead and did the 0:12:02.240 --> 0:12:06.480 risk the risk assessment, and if they hadn't done that, 0:12:06.520 --> 0:12:08.679 then maybe they wouldn't have taken that. So I am 0:12:08.720 --> 0:12:11.240 trying to find the order and trying to get women 0:12:11.280 --> 0:12:14.720 to understand because I don't understand what the understand what 0:12:14.800 --> 0:12:17.480 they should They run out and get online see their 0:12:17.520 --> 0:12:19.800 risk assessment score and then immediately go talk to the 0:12:19.800 --> 0:12:22.240 doctor about it. Is that what everybody should be doing. 0:12:22.880 --> 0:12:24.960 I think everyone has to be aware of what's going 0:12:24.960 --> 0:12:29.080 on in her own personal health and that family history story. 0:12:29.200 --> 0:12:32.839 Every woman should see the doctor once a year or 0:12:33.040 --> 0:12:35.680 you know, it could be a nurse practitioner or a PA, 0:12:35.760 --> 0:12:39.400 whoever the person is who's providing your health care for 0:12:39.640 --> 0:12:44.480 a GYN exam and a clinical breast exam, so sometimes 0:12:44.520 --> 0:12:47.240 you can feel something that may not show up right 0:12:47.280 --> 0:12:50.080 away on the X ray. Also, checking under the arms 0:12:50.080 --> 0:12:54.000 for lumps is very important. So the clinical breast examination 0:12:54.920 --> 0:12:58.160 and the mammogram is the way we start. I personally, 0:12:58.600 --> 0:13:02.280 you know, as Amy knows, younger patients feel that ultrasound, 0:13:02.320 --> 0:13:05.800 that sonogram should be part of that evaluation, and then 0:13:05.960 --> 0:13:10.320 in discussing those results. It's not just when and done, 0:13:10.320 --> 0:13:13.360 you're clear, it should be a discussion afterwards, well what 0:13:13.920 --> 0:13:17.880 did my mammogram show? If there's very dense breast tissue there, 0:13:18.679 --> 0:13:22.079 do I need a follow up test? If oh, yeah, 0:13:22.160 --> 0:13:25.640 I didn't tell you my mom had breast cancer, or 0:13:25.679 --> 0:13:28.920 my mom and her two sisters had breast cancer, or 0:13:29.800 --> 0:13:33.640 in taking that reproductive history you find out that that 0:13:33.760 --> 0:13:37.439 person had their first child over age thirty, and maybe 0:13:37.720 --> 0:13:41.120 you know other issues in their personal health that might trigger. 0:13:41.840 --> 0:13:44.560 In this case, it triggered you know, Olivia's doctor to 0:13:44.679 --> 0:13:48.720 run that risk assessment score. It's not wrong for someone 0:13:48.800 --> 0:13:52.160 to go online and do it herself. We just want 0:13:52.160 --> 0:13:57.360 to be careful that people don't get misinterpreted. So once 0:13:57.400 --> 0:13:59.920 you run it, go in and talk to an extra 0:14:00.360 --> 0:14:02.240 about what that means and what you should do. 0:14:11.120 --> 0:14:11.160 That. 0:14:11.280 --> 0:14:13.520 I hear you right that a lot of women may 0:14:13.559 --> 0:14:17.200 be getting the risk assessment and don't even know it 0:14:17.200 --> 0:14:19.160 because they might be in there with their doctor. It 0:14:19.200 --> 0:14:21.000 sounds like you were saying you were asking the questions 0:14:21.000 --> 0:14:23.000 and doing the risk assessment even though the woman didn't 0:14:23.000 --> 0:14:24.080 realize that. 0:14:24.160 --> 0:14:26.160 Then I told her. They told her about Yeah, you 0:14:26.200 --> 0:14:28.360 have to always tell them like right, what it is? 0:14:28.560 --> 0:14:32.520 Right? And it's interesting because we've had this conversation. I 0:14:32.760 --> 0:14:35.880 was among the more than eighty percent of breast cancer 0:14:36.040 --> 0:14:38.840 patients who have no family history, so I would have 0:14:38.920 --> 0:14:41.720 been considered average risk. I wouldn't have considered myself at 0:14:41.760 --> 0:14:45.560 elevated risk. But you mentioned this to me way back 0:14:45.600 --> 0:14:48.000 when my daughters were really young. Now, but now Avis 0:14:48.000 --> 0:14:51.360 twenty one and Analyse is about to be eighteen, and 0:14:52.400 --> 0:14:55.280 you had said, because of my history, their history is 0:14:55.320 --> 0:14:57.680 now they are at an elevated risk. 0:14:57.720 --> 0:14:58.960 Correct, So what. 0:14:59.720 --> 0:15:02.680 Is the age because it's been so confusing for women 0:15:03.000 --> 0:15:05.520 who are of average risk when they should have their 0:15:05.520 --> 0:15:09.160 first mammogram. But what about people like my daughters whose 0:15:09.240 --> 0:15:12.440 mom had breast cancer at a young age, When should 0:15:12.520 --> 0:15:13.640 they have their first mammogram? 0:15:13.760 --> 0:15:16.760 Is that clear? Yes? What we do is that we 0:15:16.920 --> 0:15:22.000 recommend they start seeing an expert ten years before the 0:15:22.200 --> 0:15:28.040 age at which their mom was diagnosed, so thirty round thirty. 0:15:28.080 --> 0:15:30.800 That doesn't mean they have to go into a whole 0:15:30.920 --> 0:15:34.400 intensive thing, but they have to talk to someone who 0:15:34.440 --> 0:15:38.920 is an expert and go through their personal history, maybe 0:15:39.000 --> 0:15:42.160 run a risk assessment score, and then figure out, okay, 0:15:42.160 --> 0:15:45.320 what's going to be the best way of keeping track 0:15:45.360 --> 0:15:47.960 of them and getting started a little bit early or 0:15:48.040 --> 0:15:51.280 so we're ahead of the curve and watching closely. 0:15:51.560 --> 0:15:54.520 I mean, obviously I had access to the best doctors 0:15:54.560 --> 0:15:58.120 in the world, you doctor Ratz and the incredible surgeons 0:15:58.120 --> 0:15:59.880 and everyone there at NYU Langona, and I had a 0:16:00.040 --> 0:16:04.600 credible insurance. For women who don't have those means or 0:16:04.640 --> 0:16:07.400 have access to healthcare like that, are they going to 0:16:07.560 --> 0:16:10.440 find it hard? Say they go online and they take 0:16:10.440 --> 0:16:12.440 this breast cancer risk assessment test and they see it's 0:16:12.440 --> 0:16:17.200 elevated significantly above that twelve percent average. What are their options? 0:16:17.280 --> 0:16:21.080 Will they What could you suggest to them? What is 0:16:21.120 --> 0:16:22.000 your advice to them? 0:16:22.600 --> 0:16:25.960 Well, first of all, we have an amazing network of 0:16:26.560 --> 0:16:33.360 National Cancer Institute designated cancer centers in every state of 0:16:33.400 --> 0:16:36.800 the Union, all fifty states. Now we have you know, 0:16:36.840 --> 0:16:38.920 four or five of them right here in New York City, 0:16:39.280 --> 0:16:42.760 So we have a lot of density of population and 0:16:42.840 --> 0:16:46.520 a lot of healthcare providers. In other parts of the country, 0:16:46.600 --> 0:16:50.400 it could be a big geographic distance for someone to 0:16:50.440 --> 0:16:54.840 travel to, but at least if you end up at 0:16:55.000 --> 0:17:00.200 a cancer center or a university medical center, or or 0:17:00.240 --> 0:17:04.360 a medical center affiliated with a medical school. So we're 0:17:04.400 --> 0:17:08.320 talking about places that are a little more academic. You'll 0:17:08.320 --> 0:17:12.560 get access to someone who's an expert. There are some 0:17:12.760 --> 0:17:17.320 other organizations that are out there that provide amazing information 0:17:17.400 --> 0:17:20.720 and screening for women. Planned Parenthood is one of them. 0:17:21.480 --> 0:17:24.320 People think Planned Parenthood was only out there to provide 0:17:24.359 --> 0:17:28.440 contraception and help women if they needed to terminate a pregnancy, 0:17:29.000 --> 0:17:33.199 but actually they also provide the entry point into the 0:17:33.200 --> 0:17:38.639 healthcare system for breast health as well. And other organizations 0:17:38.680 --> 0:17:41.680 that are out there with who can provide services at 0:17:41.720 --> 0:17:47.200 low cost or accepting insurances that are like Medicaid or 0:17:47.320 --> 0:17:50.640 public health insurance, but all the major medical centers will 0:17:50.960 --> 0:17:54.600 accept other insurances. And here in New York City, for example, 0:17:54.640 --> 0:17:58.640 in our public hospital system, Health and Hospitals Corporation HC 0:17:58.720 --> 0:18:02.120 hospitals can go in even without insurance and be seen 0:18:02.160 --> 0:18:04.120 in our breast clinic and be evaluated. 0:18:04.840 --> 0:18:07.280 Can you give some perspective to this Olivia mun story 0:18:07.280 --> 0:18:09.320 that it's getting a lot of attention. She's a famous person. 0:18:09.359 --> 0:18:11.520 She put it out there, and that's great to bring 0:18:11.560 --> 0:18:16.000 attention to. But just how rare is a case like hers, 0:18:16.000 --> 0:18:19.200 and that a mammogram didn't catch something, you'd then take 0:18:19.240 --> 0:18:22.040 a risk assessment, and the mammogram missed that she has 0:18:22.080 --> 0:18:25.280 this aggressive form of breast cancer in both breasts. Is 0:18:25.320 --> 0:18:27.720 this that kind of an anomaly of a case here. 0:18:27.600 --> 0:18:29.960 Well, I think it's not so unusual in our young 0:18:30.040 --> 0:18:33.440 patients where the mammogram is not necessarily the best test 0:18:33.920 --> 0:18:36.719 because of that dense breast tissue. And maybe she had 0:18:36.720 --> 0:18:39.880 an ultrasound or an MRI or something. She had both, 0:18:39.920 --> 0:18:44.520 she had both after the risk assessment test. I know 0:18:44.560 --> 0:18:47.200 they keep saying this is an aggressive form of breast cancer, 0:18:47.760 --> 0:18:51.560 but I think that's a strong word. She chose that word. 0:18:53.080 --> 0:18:56.359 And I'll give you a little biology lesson here. Breast 0:18:56.359 --> 0:19:00.600 cancer is not just one disease. There are many types 0:19:00.720 --> 0:19:05.280 of breast cancer. She really has an intermediate form. I 0:19:05.320 --> 0:19:08.320 think that luminole B I've I've never even heard of it. 0:19:08.560 --> 0:19:14.320 So we have four molecular subtypes of breast cancer. Luminal 0:19:14.560 --> 0:19:20.080 A B and then the her too enriched or her 0:19:20.080 --> 0:19:24.560 too new positive breast cancer, and then the basoloid breast cancer, 0:19:24.600 --> 0:19:29.240 which is unfortunately called triple negative, which is kind of 0:19:29.280 --> 0:19:32.720 not a great name, But what that's referring to are 0:19:32.760 --> 0:19:35.840 the three receptors that we look at that give us 0:19:35.880 --> 0:19:39.200 a lot of information about the biologic behavior of that cancer, 0:19:39.240 --> 0:19:43.440 and that's the estrogen and progesterone receptors, the hormone receptors. 0:19:43.920 --> 0:19:47.760 Those are the luminal A and B cancers. And then 0:19:47.800 --> 0:19:50.800 there's the her too positive that's her too new positive 0:19:51.080 --> 0:19:55.560 and triple negative means there's no receptors present for estrogen, 0:19:55.600 --> 0:19:58.240 progester on her too new. All three of those are absent, 0:19:59.040 --> 0:20:01.840 and that helps us to determine what treatments to use 0:20:02.080 --> 0:20:05.879 in targeting the cancer and making sure we're treating that 0:20:05.960 --> 0:20:10.480 individual with the right kind of treatment. So, the estrogen 0:20:10.560 --> 0:20:15.639 positive breast cancers are all luminal and we subdivide them 0:20:15.680 --> 0:20:18.600 into A and B, and there are tests that we 0:20:18.680 --> 0:20:22.720 can use that help us figure out which subtype it 0:20:22.880 --> 0:20:25.720 is and that helps us determine if we should add 0:20:25.800 --> 0:20:31.520 chemotherapy to just the anti estrogen endocrine therapy. And Amy 0:20:31.560 --> 0:20:34.880 knows about that. Yes, I do do genomic assays. One 0:20:34.880 --> 0:20:38.439 of them is called the acotype test. There's also a 0:20:38.560 --> 0:20:41.879 mamma print test. There are several tests we can run 0:20:42.080 --> 0:20:46.000 on the tumor tissue that tells us Okay, we know 0:20:46.080 --> 0:20:50.760 it's estrogen receptor positive, but are there other factors at 0:20:50.760 --> 0:20:53.520 play here which tell us, well, maybe we need to 0:20:53.560 --> 0:20:55.000 add a little something else to the treatment. 0:20:55.560 --> 0:20:56.520 And I'm sorry, just a quick thing. 0:20:56.600 --> 0:20:59.000 So it's not super super aggressive, but it's a little 0:20:59.000 --> 0:20:59.840 more aggressive than. 0:20:59.800 --> 0:21:02.719 The you said, not super aggressive and not necessarily an 0:21:02.720 --> 0:21:06.080 anomaly because a mammogram isn't the best test for a 0:21:06.119 --> 0:21:08.959 younger woman. When you say young in your world, when 0:21:08.960 --> 0:21:10.840 you talk in breast cancer and women young, what is 0:21:10.880 --> 0:21:12.920 the age we're talking about when you're thinking. 0:21:12.640 --> 0:21:15.840 Young, less than forty five? 0:21:16.000 --> 0:21:17.920 Okay, yeah, she's forty three. 0:21:18.040 --> 0:21:18.920 Yeah she's forty three. 0:21:19.080 --> 0:21:21.320 And you know, it is remarkable hearing you talk about 0:21:21.600 --> 0:21:23.720 there have been so many advances. I mean even when 0:21:23.720 --> 0:21:27.480 I was diagnosed ten years ago, I got the ANCA 0:21:27.640 --> 0:21:30.280 score and you were able. That was I remember you 0:21:30.320 --> 0:21:34.080 sat me down and you said, sorry, you got chemotherapy 0:21:34.119 --> 0:21:37.560 ahead of you because my AUNCA score was I believe intermediate. 0:21:37.720 --> 0:21:40.880 And you can actually predict or at least say whether 0:21:40.960 --> 0:21:42.760 or not what your chances are of having it recur 0:21:42.800 --> 0:21:45.080 and become metastatic. So I think mine's intermediate. 0:21:45.160 --> 0:21:48.720 It was, And it's not just that score. We also 0:21:48.760 --> 0:21:52.359 look at the clinical factors, age, size of the tumor, 0:21:52.760 --> 0:21:55.040 did any cells get into the lymph node? And we 0:21:55.200 --> 0:21:58.199 put all of that together. So you know, nothing in 0:21:58.200 --> 0:22:00.479 medicine is just like an on off switch. It's not 0:22:00.640 --> 0:22:03.240 just one thing that determines what we do. It's kind 0:22:03.280 --> 0:22:08.360 of all of the information and then that soft thing 0:22:08.400 --> 0:22:11.480 we call clinical judgment. That's why you can't replace me 0:22:11.560 --> 0:22:16.600