1 00:00:01,320 --> 00:00:04,280 Speaker 1: Welcome to Stuff You Missed in History Class, a production 2 00:00:04,400 --> 00:00:10,960 Speaker 1: of iHeartRadio. 3 00:00:11,920 --> 00:00:14,640 Speaker 2: Hello, and welcome to the podcast. I'm Tracy V. 4 00:00:14,800 --> 00:00:16,599 Speaker 1: Wilson and I'm Holly Frye. 5 00:00:17,280 --> 00:00:19,560 Speaker 2: Back at the end of twenty twenty three, I had 6 00:00:21,120 --> 00:00:25,720 Speaker 2: more mammograms than has been typical for me so far 7 00:00:25,960 --> 00:00:29,960 Speaker 2: in my life. I know, going back for additional imaging 8 00:00:30,160 --> 00:00:33,240 Speaker 2: is a routine experience for some folks, and it can 9 00:00:33,280 --> 00:00:37,800 Speaker 2: be really scary. For me, this was a new experience. Ultimately, 10 00:00:37,960 --> 00:00:42,920 Speaker 2: everything was fine, but of course all of that made 11 00:00:43,000 --> 00:00:46,440 Speaker 2: me think about where this all came from. And we 12 00:00:46,479 --> 00:00:50,159 Speaker 2: have also gotten some requests for a history of mammography 13 00:00:50,320 --> 00:00:51,000 Speaker 2: over the years. 14 00:00:51,800 --> 00:00:52,479 Speaker 1: While I was. 15 00:00:52,440 --> 00:00:55,560 Speaker 2: Working on this, I was astonished at how much of 16 00:00:55,560 --> 00:01:01,280 Speaker 2: it happened during hollyson My lifetime. Like I had sort 17 00:01:01,320 --> 00:01:06,640 Speaker 2: of imagined my grandmother's going to get a baseline mammogram 18 00:01:06,959 --> 00:01:11,200 Speaker 2: in some kind of old timey mammography machine in the 19 00:01:11,240 --> 00:01:16,720 Speaker 2: fifties or early sixties. There were not even old timy 20 00:01:16,800 --> 00:01:21,240 Speaker 2: mammography machines at that point. Uh. And something I want 21 00:01:21,280 --> 00:01:23,800 Speaker 2: to be super clear about from the top of the 22 00:01:23,840 --> 00:01:26,600 Speaker 2: show is that we are going to be talking about 23 00:01:26,760 --> 00:01:31,720 Speaker 2: some of the recommendations on who should get a mammogram 24 00:01:31,800 --> 00:01:37,240 Speaker 2: and when, and some questions and controversies about mammography and 25 00:01:37,319 --> 00:01:41,200 Speaker 2: other kinds of breast imaging. This is not medical advice. 26 00:01:42,360 --> 00:01:47,039 Speaker 2: Holly and I are not doctors. Please do not especially 27 00:01:47,280 --> 00:01:51,400 Speaker 2: avoid getting a mammogram based on our summary of debates 28 00:01:51,400 --> 00:01:54,960 Speaker 2: about it from the seventies or whatever like. 29 00:01:55,280 --> 00:01:57,800 Speaker 1: No, that's for a doctor discussion. 30 00:01:58,240 --> 00:02:04,560 Speaker 2: There are still debates, they are ongoing. My advice is, 31 00:02:05,320 --> 00:02:07,560 Speaker 2: I know this is hard, especially in the United States, 32 00:02:07,560 --> 00:02:11,600 Speaker 2: but try to find a provider you trust and discuss 33 00:02:11,639 --> 00:02:12,600 Speaker 2: it with them. Yes. 34 00:02:13,760 --> 00:02:17,200 Speaker 1: The history of mimography begins with the discovery of X rays. 35 00:02:17,720 --> 00:02:21,320 Speaker 1: In November of eighteen ninety five, Wilhelm Conrad Runkin was 36 00:02:21,360 --> 00:02:24,600 Speaker 1: experimenting with a Crooks tube. This is a type of 37 00:02:24,680 --> 00:02:27,600 Speaker 1: cathode ray tube, named for Sir William Crooks, who was 38 00:02:27,639 --> 00:02:30,440 Speaker 1: one of several people to develop similar tubes in the 39 00:02:30,440 --> 00:02:34,720 Speaker 1: eighteen sixties and seventies. This was a vacuum sealed container 40 00:02:34,800 --> 00:02:37,800 Speaker 1: made of glass with electrodes allowing a current to pass 41 00:02:37,840 --> 00:02:40,480 Speaker 1: through it that would cause the tube to glow. 42 00:02:41,320 --> 00:02:45,760 Speaker 2: Uh. That is not the most precise explanation of what 43 00:02:45,880 --> 00:02:49,119 Speaker 2: this was, but I feel like we're not a physics podcast, 44 00:02:49,160 --> 00:02:54,520 Speaker 2: So It's okay. Runkin's discovery is often described as accidental, 45 00:02:54,720 --> 00:02:58,320 Speaker 2: but he was intentionally experimenting to try to figure out 46 00:02:58,360 --> 00:03:02,400 Speaker 2: if the Crooks tube was emitting something other than visible light. 47 00:03:03,280 --> 00:03:06,520 Speaker 2: He had placed an opaque wrapper around the tube, and 48 00:03:06,560 --> 00:03:08,840 Speaker 2: when he started the current to make sure that rapper 49 00:03:08,960 --> 00:03:11,960 Speaker 2: was blocking out all the light, some very un platino 50 00:03:12,080 --> 00:03:16,240 Speaker 2: cyanide on a piece of cardboard several feet away started 51 00:03:16,280 --> 00:03:21,400 Speaker 2: to glow. So you could describe that one moment as 52 00:03:21,440 --> 00:03:24,640 Speaker 2: an accidental discovery because he was basically checking on his 53 00:03:24,720 --> 00:03:27,360 Speaker 2: setup when he noticed this glow, but it was in 54 00:03:27,440 --> 00:03:32,360 Speaker 2: the context of a deliberate investigation. He had been studying 55 00:03:32,520 --> 00:03:36,000 Speaker 2: light phenomena for a while. The accident was that he 56 00:03:36,160 --> 00:03:38,520 Speaker 2: got data back sooner than he expected. 57 00:03:38,520 --> 00:03:43,120 Speaker 1: To write. Soon, Runkin realized that whatever the cathodeery tube 58 00:03:43,160 --> 00:03:46,960 Speaker 1: was emitting could affect a photographic plate in addition to 59 00:03:47,000 --> 00:03:49,280 Speaker 1: passing through the shroud he was using to block the 60 00:03:49,360 --> 00:03:53,000 Speaker 1: visible light. These mysterious rays seemed to pass right through 61 00:03:53,080 --> 00:03:57,560 Speaker 1: various substances, including a plywood door, but they were blocked 62 00:03:57,560 --> 00:03:59,760 Speaker 1: by a strip of beating that had been stuck to 63 00:03:59,800 --> 00:04:02,800 Speaker 1: the or with lead. When he put his wife's hand 64 00:04:02,800 --> 00:04:05,760 Speaker 1: in front of the photographic plate. The resulting image clearly 65 00:04:05,800 --> 00:04:08,720 Speaker 1: showed her bones and the rings she was wearing. 66 00:04:09,560 --> 00:04:12,200 Speaker 2: That image, of course, is often described as the first 67 00:04:12,560 --> 00:04:16,840 Speaker 2: X ray. Runkin reported his discovery at the end of December, 68 00:04:17,160 --> 00:04:20,240 Speaker 2: using the term X rays because the nature of these 69 00:04:20,360 --> 00:04:24,400 Speaker 2: rays was at the time unknown. Today we know that 70 00:04:24,600 --> 00:04:28,359 Speaker 2: X ray radiation is part of the electromagnetic spectrum, with 71 00:04:28,440 --> 00:04:33,080 Speaker 2: a higher frequency than visible or ultraviolet light. By mid 72 00:04:33,160 --> 00:04:37,159 Speaker 2: January eighteen ninety six, so almost immediately after Runkin made 73 00:04:37,160 --> 00:04:41,200 Speaker 2: his announcement, doctors and researchers were finding medical and dental 74 00:04:41,279 --> 00:04:44,799 Speaker 2: uses for X rays, like producing images of broken bones, 75 00:04:44,960 --> 00:04:49,200 Speaker 2: foreign objects in the body, and teeth. Most soft tissue 76 00:04:49,279 --> 00:04:51,560 Speaker 2: doesn't show up well on an X ray, but soon 77 00:04:51,640 --> 00:04:53,640 Speaker 2: doctors had figured out that they could X ray the 78 00:04:53,680 --> 00:04:58,120 Speaker 2: digestive system if the patient ingested a contrast agent like 79 00:04:58,320 --> 00:05:02,159 Speaker 2: barium sulfate. He also figured out that controlled exposure to 80 00:05:02,320 --> 00:05:06,760 Speaker 2: X rays could treat certain cancers. Runkin was awarded the 81 00:05:06,760 --> 00:05:10,400 Speaker 2: Nobel Prize in Physics for his discovery in nineteen oh one, 82 00:05:10,839 --> 00:05:16,440 Speaker 2: and the field of radiology is also called runkinology. For years, 83 00:05:16,839 --> 00:05:20,760 Speaker 2: X ray images were also known as Runkin photographs. But 84 00:05:20,800 --> 00:05:23,520 Speaker 2: of course, at this point people didn't have a clear 85 00:05:23,640 --> 00:05:27,360 Speaker 2: sense of how long exposure should be, or how best 86 00:05:27,400 --> 00:05:30,400 Speaker 2: to position people, or the damaging effects of too much 87 00:05:30,520 --> 00:05:35,440 Speaker 2: radiation exposure. Accounts from the first years after Runkin's discovery 88 00:05:35,600 --> 00:05:40,000 Speaker 2: describe exposure times of thirty minutes or an hour, or, 89 00:05:40,040 --> 00:05:42,360 Speaker 2: in the case of William Levy in July of eighteen 90 00:05:42,440 --> 00:05:46,159 Speaker 2: ninety six, a whole series of exposures lasting from eight 91 00:05:46,279 --> 00:05:50,160 Speaker 2: in the morning until ten at night. This was done 92 00:05:50,200 --> 00:05:52,960 Speaker 2: at his requests. They were trying to locate a bullet 93 00:05:52,960 --> 00:05:54,880 Speaker 2: that had been in his head since being shot by 94 00:05:54,920 --> 00:05:59,240 Speaker 2: a bank robber ten years before. Although doctors did obtain 95 00:05:59,279 --> 00:06:01,440 Speaker 2: a good image of the bullet, Levy was one of 96 00:06:01,520 --> 00:06:05,760 Speaker 2: many patients who was harmed by this radiation exposure. His 97 00:06:05,839 --> 00:06:09,400 Speaker 2: whole head became blistered and swollen, he lost all of 98 00:06:09,400 --> 00:06:12,920 Speaker 2: his hair on one side, and his lips cracked and bled. 99 00:06:14,200 --> 00:06:18,279 Speaker 2: Other patients also experienced things like burns and hair loss, 100 00:06:18,320 --> 00:06:20,680 Speaker 2: and a number of practitioners who were exposed to X 101 00:06:20,720 --> 00:06:24,560 Speaker 2: ray radiation over the course of years developed cancer later 102 00:06:24,600 --> 00:06:29,520 Speaker 2: in their lives. While there were medical uses for X rays, 103 00:06:29,560 --> 00:06:33,240 Speaker 2: pretty much immediately after their discovery, it took some time 104 00:06:33,560 --> 00:06:37,880 Speaker 2: before researchers tried to X ray breast tissue. The first 105 00:06:37,920 --> 00:06:40,960 Speaker 2: person known to have done this is Albert Solomon, who 106 00:06:41,040 --> 00:06:45,039 Speaker 2: was working at the University Hospital in Berlin. He studied 107 00:06:45,040 --> 00:06:48,880 Speaker 2: tissue from three thousand breasts, and some accounts that I 108 00:06:48,920 --> 00:06:53,039 Speaker 2: read described this as coming from patients who had had mastectomies. 109 00:06:53,839 --> 00:06:56,960 Speaker 2: Others described it as tissue that had come from the morgue. 110 00:06:57,680 --> 00:07:00,279 Speaker 2: I could not find a scan of this publication anywhere 111 00:07:00,400 --> 00:07:03,240 Speaker 2: in any language. I am not clear on the details. 112 00:07:04,080 --> 00:07:06,880 Speaker 1: Solomon compared the tissue to the images shown in the 113 00:07:07,040 --> 00:07:10,080 Speaker 1: X rays, and in nineteen thirteen he published a paper 114 00:07:10,160 --> 00:07:14,040 Speaker 1: in German titled Contributions to the Pathology and Clinical Medicine 115 00:07:14,080 --> 00:07:18,080 Speaker 1: of Breast Cancer and that describes how runken photographs could 116 00:07:18,080 --> 00:07:21,400 Speaker 1: show the existence and spread of breast cancer, as well 117 00:07:21,440 --> 00:07:23,840 Speaker 1: as revealed the presence of cancer that couldn't yet be 118 00:07:23,880 --> 00:07:27,840 Speaker 1: felt through touch. Although soft tissue doesn't show up well 119 00:07:27,880 --> 00:07:31,000 Speaker 1: on an X ray, breast cancer usually has a different 120 00:07:31,080 --> 00:07:34,080 Speaker 1: density than the tissue around it, and some cancers also 121 00:07:34,240 --> 00:07:38,840 Speaker 1: cause micro calcifications or calcium deposits. All of that is 122 00:07:38,960 --> 00:07:41,560 Speaker 1: visible on an X ray To be clear. These were 123 00:07:41,560 --> 00:07:44,600 Speaker 1: not very clear X rays at all, but they were there. 124 00:07:45,520 --> 00:07:49,120 Speaker 1: Solomon's work was interrupted by World War One, during which 125 00:07:49,160 --> 00:07:51,880 Speaker 1: he worked as a doctor with the German military. He 126 00:07:51,920 --> 00:07:54,480 Speaker 1: returned to the hospital after the war was over, but 127 00:07:54,600 --> 00:07:57,240 Speaker 1: in nineteen thirty three, as the Nazis came to power, 128 00:07:57,280 --> 00:08:00,600 Speaker 1: he was removed from his position because he was Jewish. 129 00:08:01,200 --> 00:08:04,720 Speaker 1: After the November Pogram, also called krystel Nacht, he was 130 00:08:04,800 --> 00:08:09,200 Speaker 1: interned at a concentration camp and the family fled Germany 131 00:08:09,280 --> 00:08:12,960 Speaker 1: after his release. His daughter Charlotte was sent to live 132 00:08:13,000 --> 00:08:15,880 Speaker 1: with grandparents in southern France, but she was captured and 133 00:08:16,000 --> 00:08:19,960 Speaker 1: killed at Auschwitz. Solomon and his wife were interned a 134 00:08:20,120 --> 00:08:23,240 Speaker 1: second time, but escaped, and they survived the rest of 135 00:08:23,280 --> 00:08:26,240 Speaker 1: the war by hiding in the Netherlands. They lived in 136 00:08:26,320 --> 00:08:29,640 Speaker 1: Amsterdam after the war was over and Solomon went into 137 00:08:29,680 --> 00:08:33,720 Speaker 1: private practice. He had had to recertify in medicine because 138 00:08:33,720 --> 00:08:38,640 Speaker 1: his German credentials were not recognized there. Some other researchers 139 00:08:38,679 --> 00:08:41,640 Speaker 1: worked with X rays and breast tissue during these years, 140 00:08:41,760 --> 00:08:45,839 Speaker 1: but not until almost fifteen years after Solomon first published 141 00:08:46,520 --> 00:08:48,439 Speaker 1: the first person known to take an X ray of 142 00:08:48,480 --> 00:08:52,400 Speaker 1: a living person's breast was German surgeon Otto Kleinschmidt. In 143 00:08:52,480 --> 00:08:55,400 Speaker 1: nineteen twenty seven, he was working under the direction of 144 00:08:55,440 --> 00:08:56,600 Speaker 1: surgeon Edwin Peer. 145 00:08:58,040 --> 00:09:01,959 Speaker 2: In nineteen thirty, radiologists Stafford Leake Warren at the University 146 00:09:01,960 --> 00:09:05,360 Speaker 2: of Rochester in New York published on a technique that 147 00:09:05,400 --> 00:09:09,000 Speaker 2: he had developed for compiling X rays taken from two 148 00:09:09,040 --> 00:09:13,080 Speaker 2: different angles. To get a stereoscopic view of the breast, 149 00:09:13,880 --> 00:09:16,440 Speaker 2: he had patients lie on their side with their arm 150 00:09:16,600 --> 00:09:19,880 Speaker 2: raised above their head, sort of stretching out the tissue 151 00:09:19,880 --> 00:09:24,520 Speaker 2: a bit. This stereoscopic view offered us somewhat more detailed 152 00:09:24,559 --> 00:09:28,920 Speaker 2: and accurate look at density changes within the breast. Warren 153 00:09:28,960 --> 00:09:31,120 Speaker 2: took X rays of the breasts of one hundred and 154 00:09:31,200 --> 00:09:34,760 Speaker 2: nineteen patients who had already been diagnosed with some kind 155 00:09:34,760 --> 00:09:39,120 Speaker 2: of breast issue and were scheduled for surgery. Using those images, 156 00:09:39,160 --> 00:09:42,280 Speaker 2: he concluded that fifty eight of them had breast cancer. 157 00:09:43,120 --> 00:09:46,160 Speaker 2: After their surgeries, he compared those results to the breast 158 00:09:46,160 --> 00:09:49,280 Speaker 2: tissue that had been removed and confirmed that fifty four 159 00:09:49,320 --> 00:09:53,520 Speaker 2: of those patients did have cancer. Four other patients had 160 00:09:53,520 --> 00:09:58,000 Speaker 2: breast cancer that Warren had not detected through his X rays. Yeah, 161 00:09:58,040 --> 00:10:02,040 Speaker 2: so basically there were four patients who he thought had 162 00:10:02,040 --> 00:10:05,440 Speaker 2: breast cancer but did not, and another four that he 163 00:10:05,520 --> 00:10:09,360 Speaker 2: had not thought had breast cancer but did. Other patients 164 00:10:09,360 --> 00:10:12,720 Speaker 2: in Warren's study, rather than having had cancer, had chronic 165 00:10:12,800 --> 00:10:17,720 Speaker 2: mastitis or benign tumors, absesses, some other issue that was 166 00:10:17,760 --> 00:10:22,280 Speaker 2: not cancer, and Warren's paper detailed what these looked like 167 00:10:22,520 --> 00:10:26,360 Speaker 2: in the X rays. This was pretty impressive, considering that 168 00:10:26,400 --> 00:10:30,160 Speaker 2: the images in Warren's X rays were not very clear 169 00:10:30,320 --> 00:10:34,840 Speaker 2: or detailed. Like if you look at a mammogram today 170 00:10:34,880 --> 00:10:37,079 Speaker 2: and you don't know how to read it, I would 171 00:10:37,080 --> 00:10:40,800 Speaker 2: say it can look not very detailed to you. These 172 00:10:40,800 --> 00:10:45,200 Speaker 2: were very blobby, like just a lot of white blobs 173 00:10:45,240 --> 00:10:49,439 Speaker 2: in vague shapes. A year after this, German researcher Walter 174 00:10:49,559 --> 00:10:53,240 Speaker 2: Vogel published a paper on using X rays to differentiate 175 00:10:53,320 --> 00:10:57,200 Speaker 2: between different types of tumors, including how to tell benign 176 00:10:57,360 --> 00:11:02,000 Speaker 2: breast lesions from malignant ones. The term mammography was coined 177 00:11:02,000 --> 00:11:05,840 Speaker 2: in nineteen thirty seven by Nymphis Frederic Hicken, a physician 178 00:11:05,840 --> 00:11:10,120 Speaker 2: and surgeon in Salt Lake City, Utah. His article Mimography 179 00:11:10,200 --> 00:11:13,520 Speaker 2: the rent Genographic Diagnosis of Breast Tumors by Means of 180 00:11:13,600 --> 00:11:18,400 Speaker 2: Contrast Media was published in the Journal Surgery, Gynecology and Obstetrics. 181 00:11:18,840 --> 00:11:21,160 Speaker 2: He was one of several people in the nineteen thirties 182 00:11:21,160 --> 00:11:23,840 Speaker 2: and forties who were looking at the use of contrast 183 00:11:23,920 --> 00:11:28,000 Speaker 2: media to get better images in breast X rays. Contrast 184 00:11:28,080 --> 00:11:31,560 Speaker 2: enhanced mimography is still around today and it's typically used 185 00:11:31,840 --> 00:11:35,600 Speaker 2: after someone has already had a mammogram without contrast, like 186 00:11:35,920 --> 00:11:39,640 Speaker 2: if that mammogram showed something that required further investigation or 187 00:11:39,640 --> 00:11:43,680 Speaker 2: to monitor progress during breast cancer treatment, especially in people 188 00:11:43,679 --> 00:11:47,160 Speaker 2: who can't get an MRI for some reason. We will 189 00:11:47,160 --> 00:11:50,120 Speaker 2: look into how mammography evolved in the nineteen forties and 190 00:11:50,160 --> 00:12:03,240 Speaker 2: fifties after a sponsor break. If you have never had 191 00:12:03,600 --> 00:12:08,760 Speaker 2: a mammogram. Today there is a machine involved, one that 192 00:12:08,880 --> 00:12:13,599 Speaker 2: is made specifically for mimmography and it compresses the breast. 193 00:12:13,960 --> 00:12:16,880 Speaker 2: But the researchers we've been talking about so far, we're 194 00:12:17,000 --> 00:12:20,080 Speaker 2: using basic X ray equipment that had not been made 195 00:12:20,160 --> 00:12:24,160 Speaker 2: specifically for breast imaging, and they also weren't compressing the 196 00:12:24,200 --> 00:12:28,280 Speaker 2: breast tissue to X ray it. The first person known 197 00:12:28,360 --> 00:12:31,000 Speaker 2: to compress the breast to try to get a better 198 00:12:31,080 --> 00:12:34,840 Speaker 2: image of it was Raoul Lebourne, who was a radiologist 199 00:12:34,920 --> 00:12:40,760 Speaker 2: from Uruguay in nineteen forty nine. He found that compressing 200 00:12:40,880 --> 00:12:44,760 Speaker 2: the breast produced clearer images and made it easier to 201 00:12:44,840 --> 00:12:49,040 Speaker 2: distinguish between cancerous and benign masses. He also found that 202 00:12:49,160 --> 00:12:53,280 Speaker 2: using a double emulsion film improved the image quality even further. 203 00:12:54,120 --> 00:12:57,720 Speaker 2: He described the presence of micro calcifications that could be 204 00:12:57,800 --> 00:13:02,040 Speaker 2: used to help identify certain cancers. Lebourne started publishing his 205 00:13:02,120 --> 00:13:04,120 Speaker 2: findings on all this in nineteen fifty one. 206 00:13:04,960 --> 00:13:10,119 Speaker 1: Lebourne wasn't using equipment made specifically for mammograms, though basically 207 00:13:10,360 --> 00:13:12,520 Speaker 1: the person stood in front of a table that was 208 00:13:12,559 --> 00:13:15,760 Speaker 1: about breast height. The breast to be x rayed was 209 00:13:15,800 --> 00:13:18,719 Speaker 1: placed on the table with the photographic film in an 210 00:13:18,800 --> 00:13:22,559 Speaker 1: envelope under it. Then there was a cone. The X 211 00:13:22,640 --> 00:13:24,920 Speaker 1: ray emitter was at the little end and the big 212 00:13:25,000 --> 00:13:27,800 Speaker 1: end was placed on the breast, applying what he described 213 00:13:28,040 --> 00:13:31,839 Speaker 1: as a slight pressure. Lebourne used a small cone when 214 00:13:31,840 --> 00:13:34,320 Speaker 1: a specific area of the breast needed to be imaged, 215 00:13:34,400 --> 00:13:37,720 Speaker 1: and a large cone to image the whole breast. 216 00:13:38,040 --> 00:13:40,400 Speaker 2: One of the other people working on breast imaging in 217 00:13:40,440 --> 00:13:43,800 Speaker 2: the nineteen fifties was Robert Egan, who started his work 218 00:13:43,880 --> 00:13:48,600 Speaker 2: during his residency in radiology. Over the course of his research, 219 00:13:48,760 --> 00:13:52,720 Speaker 2: he concluded that mimmography could use lower power X rays 220 00:13:52,760 --> 00:13:57,079 Speaker 2: than other diagnostic imaging did, and that radiologist could adjust 221 00:13:57,120 --> 00:14:01,520 Speaker 2: the power based on breast size and density. He pinpointed 222 00:14:01,600 --> 00:14:04,840 Speaker 2: a more sensitive X ray film that could provide more 223 00:14:04,920 --> 00:14:10,280 Speaker 2: detailed images and intensifying screens that could reduce blurring. He 224 00:14:10,400 --> 00:14:14,240 Speaker 2: also suggested the use of cardboard cutouts to position the 225 00:14:14,280 --> 00:14:18,839 Speaker 2: breast for the best view. Like several other researchers before him, 226 00:14:19,000 --> 00:14:21,240 Speaker 2: Egan x rayed the breasts of people who had been 227 00:14:21,240 --> 00:14:25,280 Speaker 2: diagnosed with cancer or another breast disease, comparing the X 228 00:14:25,360 --> 00:14:28,880 Speaker 2: ray image to the diagnosis they had already received. He 229 00:14:28,920 --> 00:14:31,320 Speaker 2: also compared the X rays of that breast to the 230 00:14:31,320 --> 00:14:36,680 Speaker 2: patient's other, presumably healthy breast. He sometimes detected tumors in 231 00:14:36,720 --> 00:14:39,360 Speaker 2: the other breasts that the patient and doctor had not 232 00:14:39,520 --> 00:14:43,840 Speaker 2: been aware of. Egan's initial focus had been on helping 233 00:14:44,000 --> 00:14:48,320 Speaker 2: doctors visualize known or suspected cancers in order to make 234 00:14:48,400 --> 00:14:53,120 Speaker 2: diagnoses and treatment plans, but his research also suggested that 235 00:14:53,200 --> 00:14:57,840 Speaker 2: mimography could be used as a screening tool. Between nineteen 236 00:14:57,880 --> 00:15:01,040 Speaker 2: fifty six and nineteen fifty nine, he and his colleagues 237 00:15:01,040 --> 00:15:04,040 Speaker 2: at m D. Anderson Cancer Center imaged the breasts of 238 00:15:04,080 --> 00:15:07,960 Speaker 2: a thousand patients who didn't have obvious signs of breast cancer, 239 00:15:08,680 --> 00:15:11,440 Speaker 2: and in two hundred and thirty eight of them, mimography 240 00:15:11,520 --> 00:15:16,040 Speaker 2: revealed a previously undetected tumor. Most of these tumors were 241 00:15:16,080 --> 00:15:18,320 Speaker 2: so small that they could not be felt at all. 242 00:15:18,480 --> 00:15:22,120 Speaker 2: One of them was only eight millimeters in diameter. Egan 243 00:15:22,240 --> 00:15:25,880 Speaker 2: became a proponent of the idea of screening mammograms and 244 00:15:26,040 --> 00:15:30,000 Speaker 2: later traveled all around the country training other radiologists to 245 00:15:30,040 --> 00:15:33,680 Speaker 2: do them. There was even a national study to confirm 246 00:15:33,720 --> 00:15:36,960 Speaker 2: that his techniques could be successfully taught to other people, 247 00:15:37,040 --> 00:15:40,520 Speaker 2: who could then get similar results in the mammograms they performed. 248 00:15:41,160 --> 00:15:44,720 Speaker 2: Egan was not the only one advocating for screening mammograms 249 00:15:44,760 --> 00:15:49,360 Speaker 2: around this time. Others were Jacob Gershan Cohen, and Helen Ingleby. 250 00:15:50,200 --> 00:15:54,080 Speaker 2: All through the nineteen fifties, Grushan, Cohen, and Ingleby collaborated 251 00:15:54,120 --> 00:15:57,800 Speaker 2: on research related to the breast and breast imaging, including 252 00:15:57,840 --> 00:16:00,640 Speaker 2: various ways that different pathologies could have here in an 253 00:16:00,760 --> 00:16:04,200 Speaker 2: X ray, and they also documented normal changes to the 254 00:16:04,200 --> 00:16:08,760 Speaker 2: breast due to factors like menstruation, lactation, and age, which 255 00:16:08,800 --> 00:16:12,960 Speaker 2: were also visible on X rays. They published numerous papers 256 00:16:12,960 --> 00:16:17,040 Speaker 2: together and co authored a book called Comparative Anatomy Pathology 257 00:16:17,400 --> 00:16:20,240 Speaker 2: and wrote Ganology of the Breast that was published in 258 00:16:20,320 --> 00:16:23,080 Speaker 2: nineteen sixty. So we'll take a moment here to note 259 00:16:23,080 --> 00:16:25,920 Speaker 2: that we were about halfway through this episode on mimography 260 00:16:26,080 --> 00:16:29,400 Speaker 2: and we have only just now gotten to a woman researcher. 261 00:16:30,080 --> 00:16:33,440 Speaker 2: At this point, there were not many women doctors. There 262 00:16:33,440 --> 00:16:38,440 Speaker 2: were even fewer women in specialized fields like radiology or oncology. 263 00:16:39,160 --> 00:16:42,320 Speaker 2: We have a previous episode on Elizabeth Blackwell, who was 264 00:16:42,360 --> 00:16:44,320 Speaker 2: the first woman in the US to earn an MD, 265 00:16:44,520 --> 00:16:48,520 Speaker 2: which had happened in eighteen forty nine. Helen Ingleby had 266 00:16:48,520 --> 00:16:52,120 Speaker 2: attended the London Medical School for Women, which was England's 267 00:16:52,160 --> 00:16:55,000 Speaker 2: first medical school that enrolled women, and one of its 268 00:16:55,000 --> 00:16:59,160 Speaker 2: founders was Elizabeth Blackwell. Ingleby was also one of the 269 00:16:59,200 --> 00:17:02,240 Speaker 2: Saint George's Four, which was a nickname for the four 270 00:17:02,480 --> 00:17:07,800 Speaker 2: first women to begin studying medicine at Saint George's University 271 00:17:07,800 --> 00:17:09,720 Speaker 2: of London, which was in nineteen fifteen. 272 00:17:10,440 --> 00:17:12,240 Speaker 1: Ingleby was the first. 273 00:17:11,840 --> 00:17:14,600 Speaker 2: Woman to qualify for the Bachelor of Medicine degree at 274 00:17:14,600 --> 00:17:15,400 Speaker 2: the university. 275 00:17:16,200 --> 00:17:19,679 Speaker 1: The lack of women in medicine absolutely affected the field 276 00:17:19,680 --> 00:17:23,439 Speaker 1: of mimmography and the understanding of breast cancer and just 277 00:17:23,520 --> 00:17:27,600 Speaker 1: breast health in general. There's still so much cultural baggage 278 00:17:27,720 --> 00:17:30,680 Speaker 1: around breasts and around gender, and this was even more 279 00:17:30,720 --> 00:17:33,879 Speaker 1: true in the nineteen fifties and sixties. A lot of 280 00:17:33,920 --> 00:17:38,439 Speaker 1: male doctors were uncomfortable examining women patients breasts, and a 281 00:17:38,440 --> 00:17:41,920 Speaker 1: lot of women were uncomfortable being examined by male doctors 282 00:17:42,040 --> 00:17:45,480 Speaker 1: or even talking to a male doctor or anyone else 283 00:17:45,600 --> 00:17:49,280 Speaker 1: about a concern with their breasts. Robert Egan was known 284 00:17:49,320 --> 00:17:52,160 Speaker 1: to complain about the fact that cultural taboos and hang 285 00:17:52,240 --> 00:17:54,840 Speaker 1: ups about breasts were getting in the way of medicine, 286 00:17:55,160 --> 00:17:58,240 Speaker 1: and some of his colleagues gave him crude nicknames because 287 00:17:58,280 --> 00:18:00,160 Speaker 1: of his focus on mimmography. 288 00:18:00,680 --> 00:18:03,359 Speaker 2: They're in the research for this episode. It also really 289 00:18:03,400 --> 00:18:06,320 Speaker 2: stood out to me that Helen Ingleby had been a 290 00:18:06,359 --> 00:18:10,800 Speaker 2: collaborator on work that really helped document the many ways 291 00:18:10,840 --> 00:18:14,520 Speaker 2: that a person's breasts can change due to very ordinary 292 00:18:14,560 --> 00:18:18,520 Speaker 2: things like menstruation and aging. With all of those changes 293 00:18:18,600 --> 00:18:21,960 Speaker 2: being like in the umbrella of normal, I feel like 294 00:18:22,080 --> 00:18:25,680 Speaker 2: she is the original consultant of like, no, yeah, that happens. No, 295 00:18:25,840 --> 00:18:28,120 Speaker 2: that's that's not really yeah that happens all the time. 296 00:18:30,280 --> 00:18:34,159 Speaker 2: Although Egan, Gershan, Cohen, and Ingleby were all vocal proponents 297 00:18:34,160 --> 00:18:38,080 Speaker 2: of mimmography, not a lot of radiologists were actually performing 298 00:18:38,119 --> 00:18:42,960 Speaker 2: mammograms by nineteen sixty. The nineteen sixty Annual Oration before 299 00:18:43,000 --> 00:18:46,399 Speaker 2: the Massachusetts Medical Society, which was published under the title 300 00:18:46,680 --> 00:18:49,960 Speaker 2: the Role of Diagnostic ron Geneology and Medicine in the 301 00:18:49,960 --> 00:18:53,800 Speaker 2: New England Journal of Medicine does not mention mimmography or 302 00:18:53,840 --> 00:18:58,040 Speaker 2: the breast at all. Egan had published his mimography technique 303 00:18:58,040 --> 00:19:01,720 Speaker 2: by then, but most practitioners still didn't know about it yet. 304 00:19:02,000 --> 00:19:05,160 Speaker 2: There was also no dedicated equipment to make X raying 305 00:19:05,160 --> 00:19:09,520 Speaker 2: the breast easier and more consistent. Even formal research into 306 00:19:09,560 --> 00:19:12,399 Speaker 2: mimography was still being done with X ray equipment that 307 00:19:12,520 --> 00:19:16,639 Speaker 2: was made for other purposes, and the radiologists who were 308 00:19:16,920 --> 00:19:20,040 Speaker 2: X raying the breast were mostly working with patients who 309 00:19:20,080 --> 00:19:23,720 Speaker 2: were already showing signs of breast cancer or some other 310 00:19:23,960 --> 00:19:27,680 Speaker 2: disorder or disease of the breast. This was not usually 311 00:19:27,760 --> 00:19:32,680 Speaker 2: a way to spot previously undetected problems. Although there were 312 00:19:32,880 --> 00:19:36,679 Speaker 2: anecdotes about people whose tumors had been discovered on a 313 00:19:36,680 --> 00:19:40,119 Speaker 2: breast X ray, there had not been any controlled studies 314 00:19:40,560 --> 00:19:44,360 Speaker 2: to determine whether mammograms could be used as an effective 315 00:19:44,480 --> 00:19:46,240 Speaker 2: screening tool. 316 00:19:46,359 --> 00:19:49,240 Speaker 1: This started to shift later in the sixties, in part 317 00:19:49,320 --> 00:19:53,439 Speaker 1: because the work of radiologist Philip Strax. His wife, Bertha 318 00:19:53,440 --> 00:19:56,840 Speaker 1: Goldberg Stras had died of breast cancer in nineteen forty seven, 319 00:19:57,200 --> 00:19:59,359 Speaker 1: the age of just thirty nine, and that led him 320 00:19:59,400 --> 00:20:02,040 Speaker 1: to focus his career on the detection and treatment of 321 00:20:02,080 --> 00:20:06,040 Speaker 1: breast cancer. In nineteen sixty three, he began collaborating with 322 00:20:06,119 --> 00:20:09,480 Speaker 1: Sam Shapiro, director of Research and Statistics at the Health 323 00:20:09,520 --> 00:20:13,320 Speaker 1: Insurance Plan of Greater New York or HIP or HIP, 324 00:20:13,480 --> 00:20:17,520 Speaker 1: and surgeon Lewis Vney on a large scale, randomized trial 325 00:20:17,640 --> 00:20:20,600 Speaker 1: into the efficacy of mimmography as a screening tool. 326 00:20:21,480 --> 00:20:23,800 Speaker 2: Uh, I'm just gonna admit I did not go down 327 00:20:23,800 --> 00:20:27,160 Speaker 2: the rabbit hole of whether people say this hip or hip. 328 00:20:27,160 --> 00:20:30,000 Speaker 2: We're just gonna call it hip. Participants in this study 329 00:20:30,000 --> 00:20:33,399 Speaker 2: were HIP members, and sometimes this trial is called the 330 00:20:33,480 --> 00:20:37,760 Speaker 2: HIP study. It involved sixty two thousand women between the 331 00:20:37,800 --> 00:20:41,640 Speaker 2: ages of forty and sixty four. Half were given annual 332 00:20:41,720 --> 00:20:45,919 Speaker 2: examinations that involved an interview, a breast exam, and a mammogram. 333 00:20:46,680 --> 00:20:47,720 Speaker 1: The other half. 334 00:20:47,480 --> 00:20:52,360 Speaker 2: Received their usual medical care without this annual screening, although 335 00:20:52,480 --> 00:20:55,200 Speaker 2: if their doctor gave them a breast exam or ordered 336 00:20:55,240 --> 00:20:57,400 Speaker 2: them to get a mammogram for some reason, they were 337 00:20:57,440 --> 00:20:59,680 Speaker 2: not prevented from getting one, they just were not having 338 00:20:59,680 --> 00:21:03,800 Speaker 2: a dedicated annual screening. This was a three year study, 339 00:21:03,920 --> 00:21:07,080 Speaker 2: and initially the death rate from breast cancer was reported 340 00:21:07,359 --> 00:21:10,160 Speaker 2: as forty percent lower in the group that had received 341 00:21:10,160 --> 00:21:14,240 Speaker 2: the annual breast exams. That number was later lowered to 342 00:21:14,320 --> 00:21:18,080 Speaker 2: thirty percent, but that was still dramatic. Patients in the 343 00:21:18,119 --> 00:21:20,800 Speaker 2: screening group who were diagnosed with breast cancer over the 344 00:21:20,840 --> 00:21:23,679 Speaker 2: course of the study were also far more likely to 345 00:21:23,720 --> 00:21:26,400 Speaker 2: show no signs of the disease in their lymph nodes, 346 00:21:26,960 --> 00:21:30,320 Speaker 2: meaning their cancer was probably locally confined to the breast 347 00:21:30,440 --> 00:21:34,480 Speaker 2: when it was detected. The study also acknowledged some of 348 00:21:34,560 --> 00:21:37,919 Speaker 2: the realities of the medical system and getting access to 349 00:21:38,000 --> 00:21:41,679 Speaker 2: medical care in the United States, like these were all 350 00:21:41,720 --> 00:21:43,960 Speaker 2: folks who were part of a health insurance plan, that 351 00:21:44,160 --> 00:21:47,639 Speaker 2: is a specific population of people. At the same time, 352 00:21:48,240 --> 00:21:51,280 Speaker 2: many of the hospitals in New York where mammograms were 353 00:21:51,359 --> 00:21:54,239 Speaker 2: being done were not convenient to the women who were 354 00:21:54,320 --> 00:21:57,840 Speaker 2: enrolled in this study, so the team basically turned a 355 00:21:57,960 --> 00:22:01,359 Speaker 2: van into a mobile mimography and they drove it to 356 00:22:01,400 --> 00:22:03,720 Speaker 2: the places where the women worked so that they could 357 00:22:03,760 --> 00:22:07,480 Speaker 2: be screened on their lunch break. Even with that effort, though, 358 00:22:07,560 --> 00:22:11,440 Speaker 2: a significant number of participants in this study didn't return 359 00:22:11,600 --> 00:22:14,840 Speaker 2: for their follow up exams. That reduced the number of 360 00:22:14,880 --> 00:22:17,159 Speaker 2: people who participated in the study all the way to 361 00:22:17,200 --> 00:22:17,600 Speaker 2: the end. 362 00:22:18,320 --> 00:22:21,520 Speaker 1: Preliminary results were published in the Journal of the American 363 00:22:21,560 --> 00:22:25,600 Speaker 1: Medical Association in nineteen sixty six, and another article followed 364 00:22:25,600 --> 00:22:30,080 Speaker 1: in nineteen seventy one, and overall, using mammograms to screen 365 00:22:30,160 --> 00:22:34,159 Speaker 1: people for breast cancer seemed like a clear success. Philip 366 00:22:34,200 --> 00:22:38,080 Speaker 1: Strax joined Robert Egan, Jacob Gershaan Cohen, and Helen Ingleby 367 00:22:38,119 --> 00:22:40,480 Speaker 1: in advocating for screening mammograms. 368 00:22:41,160 --> 00:22:45,560 Speaker 2: Another big breakthrough came about in nineteen sixty five in Strasbourg, France, 369 00:22:45,600 --> 00:22:49,879 Speaker 2: when radiologist Charles Gross worked with company generald At Radiology 370 00:22:50,400 --> 00:22:54,680 Speaker 2: to develop the CGR centograph. This was the first device 371 00:22:54,920 --> 00:22:58,879 Speaker 2: specifically made to X ray the breast. Gross was a 372 00:22:59,040 --> 00:23:02,640 Speaker 2: vocal advocate for breast cancer screening as well, and there 373 00:23:02,680 --> 00:23:05,679 Speaker 2: are a number of sources that describe him and Philip 374 00:23:05,760 --> 00:23:09,960 Speaker 2: Egan as the two people within the medical community who 375 00:23:10,040 --> 00:23:13,080 Speaker 2: really did the most to push the idea of screening 376 00:23:13,160 --> 00:23:17,640 Speaker 2: mammograms into the mainstream. Of course, there were also developments 377 00:23:17,640 --> 00:23:21,560 Speaker 2: that were happening from outside the medical community. In the US, 378 00:23:21,600 --> 00:23:25,400 Speaker 2: for example, President Richard Nixon announced a War on Cancer 379 00:23:25,480 --> 00:23:29,280 Speaker 2: in nineteen seventy one. A year later, the National Cancer 380 00:23:29,359 --> 00:23:32,720 Speaker 2: Institute and the American Cancer Society teamed up to launch 381 00:23:32,760 --> 00:23:38,600 Speaker 2: the Breast Cancer Detection Demonstration Project or BCDDP. The American 382 00:23:38,640 --> 00:23:42,439 Speaker 2: Cancer Society was heavily invested in this During the nineteen 383 00:23:42,520 --> 00:23:45,879 Speaker 2: fifties and sixties, the American Cancer Society had pushed for 384 00:23:46,040 --> 00:23:50,040 Speaker 2: routine cervical cancer screening using AP tests, and death rates 385 00:23:50,040 --> 00:23:53,880 Speaker 2: from cervical cancer were declining. It was hoped that routine 386 00:23:53,920 --> 00:23:56,640 Speaker 2: breast screenings would have a similar impact on deaths from 387 00:23:56,640 --> 00:24:01,760 Speaker 2: breast cancer. The BCDDP offered five years of free annual 388 00:24:01,800 --> 00:24:05,240 Speaker 2: mammograms to women over the age of thirty five. That 389 00:24:05,440 --> 00:24:09,000 Speaker 2: was at twenty nine screening centers located in twenty seven 390 00:24:09,080 --> 00:24:12,600 Speaker 2: cities around the US. More than two hundred and eighty 391 00:24:12,720 --> 00:24:15,840 Speaker 2: thousand women were screened at one of these centers between 392 00:24:15,920 --> 00:24:20,119 Speaker 2: nineteen seventy three and nineteen eighty That exceeded the project's 393 00:24:20,160 --> 00:24:22,320 Speaker 2: initial goal by more than ten thousand. 394 00:24:23,040 --> 00:24:26,040 Speaker 1: Interest in screenings also surged in the US in the 395 00:24:26,080 --> 00:24:29,520 Speaker 1: fall of nineteen seventy four after Betty Ford, wife of 396 00:24:29,560 --> 00:24:33,560 Speaker 1: President Gerald Ford, and Margaretta Rockefeller, known as Happy Wife 397 00:24:33,600 --> 00:24:37,440 Speaker 1: of Nelson Rockefeller, each announced that they had been diagnosed 398 00:24:37,480 --> 00:24:41,240 Speaker 1: with breast cancer. Although neither of their cancers had been 399 00:24:41,359 --> 00:24:45,960 Speaker 1: initially detected in a mammogram, both underwent surgery and survived, 400 00:24:46,240 --> 00:24:49,640 Speaker 1: and their public acknowledgment of what had happened helped dispel 401 00:24:49,720 --> 00:24:52,560 Speaker 1: some of the stigma and secrecy surrounding the disease. 402 00:24:53,440 --> 00:24:58,160 Speaker 2: It was also evolving that breast cancer was a survivable 403 00:24:58,160 --> 00:25:01,760 Speaker 2: and even curable disease if people caught it early, and 404 00:25:01,840 --> 00:25:05,720 Speaker 2: this was feeding into that as well. Things moved a 405 00:25:05,720 --> 00:25:08,760 Speaker 2: bit more slowly in other parts of the world. For example, 406 00:25:08,800 --> 00:25:11,960 Speaker 2: in Europe in the nineteen seventies, only Sweden and Scotland 407 00:25:12,000 --> 00:25:16,560 Speaker 2: conducted trials of screening mammograms. In Japan, as another example, 408 00:25:16,760 --> 00:25:20,880 Speaker 2: ultrasound was already being used for breast imaging, so there 409 00:25:20,960 --> 00:25:24,840 Speaker 2: just really wasn't a big focus on seeing how mimography 410 00:25:24,880 --> 00:25:25,520 Speaker 2: would work there. 411 00:25:26,040 --> 00:25:29,560 Speaker 1: There were also doubts and controversies pretty much right away. 412 00:25:30,119 --> 00:25:33,400 Speaker 1: Although the Hip study had shown a clear reduction in mortality. 413 00:25:33,440 --> 00:25:36,879 Speaker 1: In the group that had regular breast exams. Only forty 414 00:25:36,880 --> 00:25:40,240 Speaker 1: four cases of breast cancer had been found only through 415 00:25:40,320 --> 00:25:44,120 Speaker 1: mimography over the course of that study. In many other cases, 416 00:25:44,160 --> 00:25:48,280 Speaker 1: the patient's medical history, physical exam, or interview had already 417 00:25:48,320 --> 00:25:50,360 Speaker 1: suggested the possibility of cancer. 418 00:25:51,520 --> 00:25:55,239 Speaker 2: One of the people to publicly criticize the idea of 419 00:25:55,320 --> 00:26:00,359 Speaker 2: screening mammograms was John C. Baylor, who was statistician with 420 00:26:00,600 --> 00:26:05,600 Speaker 2: the National Cancer Institute. He published an article called Mimography 421 00:26:05,720 --> 00:26:08,680 Speaker 2: A Contrary View and the Annals of Internal Medicine in 422 00:26:08,800 --> 00:26:12,240 Speaker 2: January of nineteen seventy six. This is one of the 423 00:26:12,280 --> 00:26:14,440 Speaker 2: moments where I was like, this was after I was born. 424 00:26:16,880 --> 00:26:21,000 Speaker 2: His criticisms included the fact that many of the early 425 00:26:21,119 --> 00:26:25,040 Speaker 2: cancers that were being diagnosed were very slow growing masses 426 00:26:25,119 --> 00:26:27,480 Speaker 2: that might not ever reach a point where they were 427 00:26:27,520 --> 00:26:31,240 Speaker 2: a risked to the patient's life. He also expressed concerns 428 00:26:31,280 --> 00:26:35,480 Speaker 2: that the radiation exposure involved with a mammogram could contribute 429 00:26:35,520 --> 00:26:39,560 Speaker 2: to breast cancers later in life. I'll pause to say 430 00:26:40,200 --> 00:26:43,600 Speaker 2: the amount of radiation exposure is less now than it 431 00:26:43,720 --> 00:26:47,240 Speaker 2: was in nineteen seventy six. He argued that the government 432 00:26:47,359 --> 00:26:52,879 Speaker 2: should have been focusing its efforts on further randomized controlled trials, 433 00:26:53,080 --> 00:26:56,880 Speaker 2: including trials specifically looking at the question of whether screening 434 00:26:56,920 --> 00:27:00,160 Speaker 2: mammograms were worthwhile in patients under the age of fifty, 435 00:27:00,840 --> 00:27:04,679 Speaker 2: and studies on more diverse groups of people, rather than 436 00:27:04,720 --> 00:27:10,440 Speaker 2: a demonstration project like the BCDDP. Baylor initially criticized all 437 00:27:10,560 --> 00:27:13,960 Speaker 2: screening mammograms, but eventually really focused his attention on the 438 00:27:13,960 --> 00:27:16,680 Speaker 2: ones performed on women under the age of fifty. 439 00:27:17,600 --> 00:27:20,960 Speaker 1: The same year that Baylor published this article, the American 440 00:27:21,000 --> 00:27:25,480 Speaker 1: Cancer Society started recommending mimography for early breast cancer detection. 441 00:27:26,080 --> 00:27:28,359 Speaker 1: We'll talk more about that after a sponsor break. 442 00:27:38,040 --> 00:27:42,679 Speaker 2: The American Cancer Society had started educational campaigns recommending that 443 00:27:42,720 --> 00:27:46,000 Speaker 2: women examined their own breasts for signs of cancer in 444 00:27:46,040 --> 00:27:50,320 Speaker 2: the nineteen thirties and forties. That, plus the increased use 445 00:27:50,359 --> 00:27:53,480 Speaker 2: of screening mammograms in the late sixties and seventies, meant 446 00:27:53,560 --> 00:27:57,560 Speaker 2: that more people were being diagnosed with breast cancer earlier 447 00:27:57,600 --> 00:28:02,040 Speaker 2: than they might have been otherwise. But for decades, the 448 00:28:02,240 --> 00:28:05,400 Speaker 2: standard treatment for breast cancer in the US and much 449 00:28:05,400 --> 00:28:10,080 Speaker 2: of Europe had involved a radical mastectomy. This surgery was 450 00:28:10,119 --> 00:28:13,760 Speaker 2: developed by William Stewart Halstead all the way back in 451 00:28:13,840 --> 00:28:17,440 Speaker 2: eighteen eighty two, building on the work of earlier doctors. 452 00:28:17,960 --> 00:28:21,840 Speaker 2: This included the removal of the breast and adjacent parts 453 00:28:21,840 --> 00:28:25,320 Speaker 2: of the lymphatic system and the pectoralis major muscle. 454 00:28:26,200 --> 00:28:30,200 Speaker 1: That's a major surgery. But when Halsta developed it, most 455 00:28:30,280 --> 00:28:33,399 Speaker 1: breast cancers were detected when tumors were large enough to 456 00:28:33,480 --> 00:28:36,720 Speaker 1: be obvious and had started to spread beyond the breast. 457 00:28:37,480 --> 00:28:40,480 Speaker 1: But at least in theory, cancers that were discovered earlier 458 00:28:40,640 --> 00:28:44,280 Speaker 1: might not need such a broad response. This led to 459 00:28:44,400 --> 00:28:47,000 Speaker 1: questions of whether mammograms were going to lead to people 460 00:28:47,040 --> 00:28:51,440 Speaker 1: having major surgery that they didn't actually need. So this 461 00:28:51,560 --> 00:28:55,160 Speaker 1: ties into the history of breast cancer treatment, which of 462 00:28:55,200 --> 00:28:58,880 Speaker 1: course could be a whole separate topic. The first chemotherapy 463 00:28:58,960 --> 00:29:02,080 Speaker 1: drugs were developed in the nineteen forties and fifties. As 464 00:29:02,120 --> 00:29:06,120 Speaker 1: we said, earlier experiments in radiotherapy as a cancer treatment 465 00:29:06,160 --> 00:29:09,200 Speaker 1: had started almost immediately after the discovery. 466 00:29:08,720 --> 00:29:13,760 Speaker 2: Of X rays. Surgeon John Madden modified Halsted's methods for 467 00:29:13,960 --> 00:29:18,400 Speaker 2: the radical mastectomy in nineteen seventy two, with Madden's techniques 468 00:29:18,680 --> 00:29:24,360 Speaker 2: preserving the pectoral missiles. Oncologist Umberto VERNESSI also promoted a 469 00:29:24,560 --> 00:29:29,560 Speaker 2: more conservative surgery described as a quadrant ectomy, combining that 470 00:29:29,640 --> 00:29:35,400 Speaker 2: with radiotherapy. Studies comparing the efficacy of radical mastectomies with 471 00:29:35,600 --> 00:29:39,880 Speaker 2: Vernesi's methods started in Milan in nineteen seventy three, and 472 00:29:39,960 --> 00:29:43,240 Speaker 2: this was part of a whole process of figuring out 473 00:29:43,280 --> 00:29:46,760 Speaker 2: how to successfully treat breast cancers that were detected earlier 474 00:29:47,560 --> 00:29:51,440 Speaker 2: without overtreating them, like, without giving people a more intense 475 00:29:51,560 --> 00:29:53,320 Speaker 2: treatment than they actually needed. 476 00:29:54,120 --> 00:29:57,680 Speaker 1: Complicating all of this was the fact that screening mammograms 477 00:29:57,680 --> 00:30:01,320 Speaker 1: were identifying growths that were ambiguous. In other words, it 478 00:30:01,360 --> 00:30:05,000 Speaker 1: wasn't obvious whether they were or were not cancerous. While 479 00:30:05,000 --> 00:30:09,600 Speaker 1: the BCDDP was ongoing, a preliminary report suggested that sixty 480 00:30:09,640 --> 00:30:13,480 Speaker 1: six of five hundred six pathological specimens collected so far 481 00:30:13,880 --> 00:30:17,720 Speaker 1: had not actually contained any sign of cancer nor carcinoma 482 00:30:17,800 --> 00:30:22,240 Speaker 1: in situ. Today, carcinoma in situ is sometimes called stage 483 00:30:22,320 --> 00:30:26,560 Speaker 1: zero cancer, and it involves precancerous cells that have not spread, 484 00:30:26,640 --> 00:30:30,640 Speaker 1: which may or may not become cancerous. Of those sixty 485 00:30:30,680 --> 00:30:33,920 Speaker 1: six specimens that didn't have any evidence of cancerous or 486 00:30:33,960 --> 00:30:38,000 Speaker 1: precancerous cells, fifty three had led the patient to undergo 487 00:30:38,400 --> 00:30:42,840 Speaker 1: some type of mastectomy. The researcher stressed that the mammograms 488 00:30:42,840 --> 00:30:45,800 Speaker 1: were not to blame for this, that other doctors had 489 00:30:45,800 --> 00:30:51,360 Speaker 1: performed those biopsies, made those diagnoses, and recommended those surgical treatments. 490 00:30:52,040 --> 00:30:54,880 Speaker 1: But all of this added to the ongoing questions about 491 00:30:54,920 --> 00:30:56,440 Speaker 1: the idea of overtreatment. 492 00:30:57,440 --> 00:31:00,680 Speaker 2: With all these kinds of questions in play and others, 493 00:31:01,160 --> 00:31:04,360 Speaker 2: various states and the US federal government started working to 494 00:31:04,520 --> 00:31:08,760 Speaker 2: regulate mammography. Between nineteen eighty six and nineteen ninety two, 495 00:31:08,880 --> 00:31:12,360 Speaker 2: a number of laws were passed requiring things like dedicated 496 00:31:12,400 --> 00:31:17,440 Speaker 2: mimmography machines at hospitals and inspections on those machines. The 497 00:31:17,640 --> 00:31:21,760 Speaker 2: US passed the Mimography Quality Standards Act in nineteen ninety two, 498 00:31:22,280 --> 00:31:25,400 Speaker 2: which was meant to help ensure the safety and efficacy 499 00:31:25,440 --> 00:31:29,680 Speaker 2: of mimmography, including making sure the amount of radiation patients 500 00:31:29,680 --> 00:31:34,520 Speaker 2: were exposed to was low. The American College of Radiology 501 00:31:34,720 --> 00:31:38,600 Speaker 2: also developed the Breast Imaging and Reporting Data System or 502 00:31:38,640 --> 00:31:43,480 Speaker 2: BIRADS in nineteen ninety three to provide standardized ways to 503 00:31:43,840 --> 00:31:48,520 Speaker 2: describe and report mammogram results. Today, the byrad's AT list 504 00:31:48,600 --> 00:31:53,000 Speaker 2: includes guidelines for multiple types of breast imaging, including mammography 505 00:31:53,200 --> 00:31:54,440 Speaker 2: ultrasound and MRI. 506 00:31:55,440 --> 00:31:59,240 Speaker 1: There were numerous advances in mimography technology and methods in 507 00:31:59,280 --> 00:32:03,720 Speaker 1: the late nineteen eighties and nineteen nineties. Digital mimography was 508 00:32:03,720 --> 00:32:06,920 Speaker 1: introduced in two thousand and one, and today most mammograms 509 00:32:06,920 --> 00:32:10,920 Speaker 1: are digital, so radiologists can see the images instantly rather 510 00:32:10,960 --> 00:32:14,840 Speaker 1: than waiting for films to be developed. Digital mimography also 511 00:32:14,880 --> 00:32:17,400 Speaker 1: tends to be more accurate in people over the age 512 00:32:17,400 --> 00:32:20,520 Speaker 1: of fifty, although the accuracy is about the same in 513 00:32:20,560 --> 00:32:25,640 Speaker 1: people younger than that. Digital temosynthesis or three D digital mimography, 514 00:32:25,800 --> 00:32:27,800 Speaker 1: was introduced in twenty eleven. 515 00:32:28,120 --> 00:32:31,000 Speaker 2: And there are other methods for breast imaging as well. 516 00:32:31,200 --> 00:32:36,720 Speaker 2: Some examples include magnetic resonance imaging or MRI, ultrasound mimography 517 00:32:36,760 --> 00:32:41,240 Speaker 2: with contrasts, which we mentioned earlier, positron emission mimography, and 518 00:32:41,520 --> 00:32:43,480 Speaker 2: breast specific gammut imaging. 519 00:32:44,120 --> 00:32:45,000 Speaker 1: A lot of these. 520 00:32:44,880 --> 00:32:49,120 Speaker 2: Today are used after a screening mammogram has revealed something 521 00:32:49,160 --> 00:32:52,920 Speaker 2: that needs further evaluation, or after somebody has been diagnosed 522 00:32:52,920 --> 00:32:56,600 Speaker 2: with breast cancer, to better visualize the tumor and to 523 00:32:56,840 --> 00:32:58,800 Speaker 2: monitor progress during treatment. 524 00:32:59,480 --> 00:33:02,320 Speaker 1: In more recent years, there have also been recommendations for 525 00:33:02,440 --> 00:33:06,320 Speaker 1: mammography to be paired with automated whole breast ultrasound in 526 00:33:06,360 --> 00:33:09,440 Speaker 1: people with dense breasts, and at this point it's usually 527 00:33:09,520 --> 00:33:13,800 Speaker 1: recommended in addition to not instead of a mammogram. But 528 00:33:13,840 --> 00:33:18,200 Speaker 1: there's also an overall higher false positive rate for breast ultrasounds, 529 00:33:18,240 --> 00:33:22,360 Speaker 1: including automated whole breast ultrasound, than there is for mammograms. 530 00:33:23,280 --> 00:33:26,080 Speaker 1: Some of the concerns about mimmography that were raised in 531 00:33:26,120 --> 00:33:29,080 Speaker 1: the wake of the Hip study continue to be debated today. 532 00:33:29,520 --> 00:33:32,920 Speaker 1: Like the Hip study had shown clear evidence that routine 533 00:33:32,960 --> 00:33:35,920 Speaker 1: breast cancer screening could reduce the number of deaths from 534 00:33:35,960 --> 00:33:39,560 Speaker 1: breast cancer in people over the age of fifty, but 535 00:33:39,640 --> 00:33:42,520 Speaker 1: there wasn't clear evidence for women between the ages of 536 00:33:42,680 --> 00:33:46,680 Speaker 1: forty and fifty. Screening mammograms really didn't seem to make 537 00:33:46,760 --> 00:33:50,200 Speaker 1: much of a difference in this age group. If you're 538 00:33:50,360 --> 00:33:53,560 Speaker 1: in that age bracket, which I am, and you've gotten 539 00:33:53,560 --> 00:33:57,200 Speaker 1: a mammogram, you may have gotten results describing your breasts 540 00:33:57,240 --> 00:34:01,320 Speaker 1: as dense. Basically, younger bread guests contain a lot more 541 00:34:01,360 --> 00:34:05,200 Speaker 1: connective tissue and other structures that show up on a mammogram, 542 00:34:05,480 --> 00:34:08,240 Speaker 1: and that can make it harder to spot small tumors, 543 00:34:08,920 --> 00:34:12,800 Speaker 1: but older breasts usually have less connective tissue and more fat, 544 00:34:12,960 --> 00:34:17,160 Speaker 1: so tumors stand out more on a mammogram. In general, 545 00:34:17,239 --> 00:34:20,839 Speaker 1: breast cancer risk also increases with age, So what's the 546 00:34:21,000 --> 00:34:25,880 Speaker 1: right age for a person to start having mammograms? Guidance 547 00:34:25,960 --> 00:34:29,239 Speaker 1: on this has changed repeatedly since the years of the 548 00:34:29,280 --> 00:34:33,640 Speaker 1: Hip study, including an incredibly controversial recommendation by the US 549 00:34:33,760 --> 00:34:37,440 Speaker 1: Preventative Services Task Force in two thousand and nine. That 550 00:34:37,520 --> 00:34:40,440 Speaker 1: recommendation was that women between the ages of forty and 551 00:34:40,600 --> 00:34:46,000 Speaker 1: forty nine not be routinely screened. There is still so 552 00:34:46,280 --> 00:34:48,719 Speaker 1: much debate about the age at which people should start 553 00:34:48,760 --> 00:34:51,719 Speaker 1: getting mammograms and how often they should get them after 554 00:34:51,760 --> 00:34:55,080 Speaker 1: that point, and there's often a lack of consensus among 555 00:34:55,120 --> 00:34:59,279 Speaker 1: different organizations and governing bodies about what those recommendations should be. 556 00:35:00,320 --> 00:35:04,000 Speaker 1: Recommendations for transgender and non binary people are even more 557 00:35:04,040 --> 00:35:07,960 Speaker 1: scattered in contradictory and are based on just really limited data. 558 00:35:08,560 --> 00:35:10,840 Speaker 1: I read through these and I found them very confusing. 559 00:35:12,360 --> 00:35:15,880 Speaker 1: And this is for a community of people. Trans and 560 00:35:15,960 --> 00:35:19,200 Speaker 1: non binary people already often having a really high bar 561 00:35:19,360 --> 00:35:23,920 Speaker 1: to getting compassionate medical care at all, just making it 562 00:35:23,960 --> 00:35:30,040 Speaker 1: more complicated and based on limited data A cynical way 563 00:35:30,400 --> 00:35:33,080 Speaker 1: to look at this debate about when and how often 564 00:35:33,080 --> 00:35:36,120 Speaker 1: people should get mammograms, especially in places like the United 565 00:35:36,160 --> 00:35:39,520 Speaker 1: States where we don't have universal health care, is that 566 00:35:39,560 --> 00:35:42,400 Speaker 1: this is all about money and what insurance companies are 567 00:35:42,400 --> 00:35:44,640 Speaker 1: willing to pay for, especially when it comes to people 568 00:35:44,719 --> 00:35:49,600 Speaker 1: under the age of fifty. There definitely are arguments about 569 00:35:49,640 --> 00:35:53,480 Speaker 1: whether routine mammograms are the cost effective way to detect 570 00:35:53,600 --> 00:35:57,360 Speaker 1: signs of breast cancer. I read some of those papers. 571 00:35:57,400 --> 00:36:02,080 Speaker 1: I found them irritating. To the National Cancer Institute, more 572 00:36:02,120 --> 00:36:05,400 Speaker 1: than seventy five percent of women in the US between 573 00:36:05,400 --> 00:36:08,440 Speaker 1: the ages of fifty and seventy four have had a 574 00:36:08,480 --> 00:36:12,560 Speaker 1: mammogram within the last two years, but more than half 575 00:36:12,640 --> 00:36:16,400 Speaker 1: of breast cancers are discovered by the patients themselves or 576 00:36:16,440 --> 00:36:19,000 Speaker 1: their partners, not from a mammogram. So that's like a 577 00:36:19,120 --> 00:36:22,160 Speaker 1: question of like, wouldn't it be cheaper to just make 578 00:36:22,200 --> 00:36:26,239 Speaker 1: sure everybody's getting regular physical exams. 579 00:36:27,080 --> 00:36:30,480 Speaker 2: I find that I'm like, this is it cheaper? I 580 00:36:30,560 --> 00:36:33,000 Speaker 2: find that to be a frustrating way to look at it. 581 00:36:33,239 --> 00:36:35,720 Speaker 1: I have a question about that that we can table 582 00:36:35,960 --> 00:36:41,520 Speaker 1: till an so frietay, sure, yes, But beyond all of that, 583 00:36:41,560 --> 00:36:44,879 Speaker 1: there are real questions about the efficacy of mimography as 584 00:36:44,920 --> 00:36:48,120 Speaker 1: a screening tool, especially in people under the age of fifty. 585 00:36:48,800 --> 00:36:51,560 Speaker 1: As we said earlier, it's not just about the fact 586 00:36:51,600 --> 00:36:54,280 Speaker 1: that a higher breast density can make small tumors harder 587 00:36:54,280 --> 00:36:57,640 Speaker 1: to see. There are also questions around the risks of 588 00:36:57,719 --> 00:37:02,240 Speaker 1: false positive and overtreatment. As we're result of earlier annual mammograms. 589 00:37:02,800 --> 00:37:06,000 Speaker 1: It's estimated that over the course of ten screenings, roughly 590 00:37:06,080 --> 00:37:09,320 Speaker 1: half of patients in the US will experience a false 591 00:37:09,360 --> 00:37:13,400 Speaker 1: positive and roughly twenty percent of patients in Europe. And 592 00:37:13,480 --> 00:37:17,479 Speaker 1: there are still lingering questions about overtreatment and whether very 593 00:37:17,520 --> 00:37:20,640 Speaker 1: small growth seen on mammograms need to be treated or 594 00:37:20,680 --> 00:37:23,520 Speaker 1: would ever jeopardize the patient's life in any way. 595 00:37:24,360 --> 00:37:26,799 Speaker 2: So we can't speak from experience about other parts of 596 00:37:26,840 --> 00:37:29,040 Speaker 2: the world. Holly and I live in the United States, 597 00:37:29,160 --> 00:37:33,240 Speaker 2: but here there are huge disparities and who has access 598 00:37:33,280 --> 00:37:37,120 Speaker 2: to screening mammograms, including who has access to the newer 599 00:37:37,160 --> 00:37:41,480 Speaker 2: technologies like three D mimography, and these disparities are often 600 00:37:41,560 --> 00:37:45,320 Speaker 2: compounded in every step of the process. So a person 601 00:37:45,320 --> 00:37:48,360 Speaker 2: who can't get an appointment, or can't get an appointment 602 00:37:48,400 --> 00:37:50,120 Speaker 2: at a place that has the most up to date 603 00:37:50,160 --> 00:37:53,920 Speaker 2: equipment or can't afford a mammogram at all, or feels 604 00:37:54,160 --> 00:37:58,520 Speaker 2: unwelcome at the doctor due to factors like medical racism 605 00:37:58,600 --> 00:38:02,000 Speaker 2: and fat phobia and trans phobia. They're gonna have these 606 00:38:02,040 --> 00:38:05,719 Speaker 2: same exact issues again when it comes to follow ups 607 00:38:05,760 --> 00:38:09,759 Speaker 2: if additional imaging is needed. Treatment can also be incredibly 608 00:38:09,880 --> 00:38:13,120 Speaker 2: expensive for breast cancer, even in people who have insurance, 609 00:38:13,239 --> 00:38:17,040 Speaker 2: and so all of this contributes to racial and economic 610 00:38:17,080 --> 00:38:21,080 Speaker 2: disparities in breast cancer detection rates and survival rates for 611 00:38:21,120 --> 00:38:24,520 Speaker 2: breast cancer, with black women in the US in particular 612 00:38:24,640 --> 00:38:29,200 Speaker 2: being a lot just disproportionately more likely to die from 613 00:38:29,239 --> 00:38:34,640 Speaker 2: the disease. I know that is a kind of dire 614 00:38:34,880 --> 00:38:36,839 Speaker 2: place to leave off the episode. 615 00:38:37,000 --> 00:38:40,719 Speaker 1: The Grim de new mal of the episode. 616 00:38:40,239 --> 00:38:43,600 Speaker 2: Yeah, I didn't feel like I could just leave that out. 617 00:38:43,960 --> 00:38:45,640 Speaker 1: Do you have less Grim listener mail? 618 00:38:45,920 --> 00:38:49,440 Speaker 2: Do I have much less Grim listener mail? Fabuloush The 619 00:38:49,480 --> 00:38:53,520 Speaker 2: clistener mail came from Dave and Dave's subject line is 620 00:38:53,640 --> 00:38:58,240 Speaker 2: just Assassin's Creed origins. Dave wrote, Hi, Holly and Tracy, 621 00:38:58,280 --> 00:39:00,200 Speaker 2: I guess I have a PhD in the show. Since 622 00:39:00,200 --> 00:39:02,440 Speaker 2: I've been listening to the podcast from the very start, 623 00:39:02,600 --> 00:39:05,439 Speaker 2: I've loved the many evolutions of the show over the years, 624 00:39:05,440 --> 00:39:07,160 Speaker 2: and I'm grateful for all the hard work you put 625 00:39:07,160 --> 00:39:10,520 Speaker 2: into it. Naturally, I've been tempted to write several times, 626 00:39:10,680 --> 00:39:14,000 Speaker 2: especially since my hometown of Saint Catherine's, Ontario has appeared 627 00:39:14,000 --> 00:39:16,120 Speaker 2: in a number of episodes, but I never felt I 628 00:39:16,160 --> 00:39:18,840 Speaker 2: had something worth sharing, well, at least until you talked 629 00:39:18,840 --> 00:39:24,080 Speaker 2: about Assassin's Creed. During the Banu Musa episode. You touched 630 00:39:24,200 --> 00:39:27,600 Speaker 2: upon how ubsoft tries to add some level of historical 631 00:39:27,640 --> 00:39:30,520 Speaker 2: accuracy to the backgrounds in the game. What you may 632 00:39:30,520 --> 00:39:33,439 Speaker 2: not realize is that historians and museums have taken note 633 00:39:33,440 --> 00:39:36,080 Speaker 2: of that. I volunteer at the Nilson Atkins Museum in 634 00:39:36,160 --> 00:39:38,719 Speaker 2: Kansas City. It's a world class museum and I love 635 00:39:38,760 --> 00:39:42,520 Speaker 2: giving tours and interacting with guests. Before the pandemic, we 636 00:39:42,600 --> 00:39:47,360 Speaker 2: had an episode on Nefertari was an amazing collaboration with 637 00:39:47,400 --> 00:39:51,319 Speaker 2: the museum, Egzo and for In Italy. Featured prominently in 638 00:39:51,360 --> 00:39:55,080 Speaker 2: the exhibit were animated outtakes from an educational version of 639 00:39:55,120 --> 00:39:59,520 Speaker 2: Assassin's Creed origins. You can find these online at Ubusov's 640 00:39:59,560 --> 00:40:02,880 Speaker 2: website and there's a link to that. Needless to say, 641 00:40:02,920 --> 00:40:05,319 Speaker 2: it was very cool to have these recreated sites next 642 00:40:05,360 --> 00:40:07,640 Speaker 2: to actual artifacts, and people love it. So I hope 643 00:40:07,640 --> 00:40:09,680 Speaker 2: you enjoy that tidbit and don't get stuck in the 644 00:40:09,760 --> 00:40:12,799 Speaker 2: rabbit hole of these Assassin's Creed discovery tours. Here's my 645 00:40:12,920 --> 00:40:17,840 Speaker 2: pet tax. What follows is an adorable black kitty cat 646 00:40:17,880 --> 00:40:21,960 Speaker 2: asleep on a cream colored carpet. Cricket is a Manx. 647 00:40:22,040 --> 00:40:24,800 Speaker 2: This breed typically do not have tails. She's got a 648 00:40:24,840 --> 00:40:27,960 Speaker 2: lot of personality and wants a lot of attention. Although 649 00:40:28,000 --> 00:40:29,920 Speaker 2: she refuses to be a lap cat. She wants her 650 00:40:29,960 --> 00:40:32,919 Speaker 2: tribute on her terms. Keep up the great work, sincerely, Dave. 651 00:40:34,640 --> 00:40:35,839 Speaker 2: I love this kitty cat. 652 00:40:35,920 --> 00:40:38,880 Speaker 1: I used to have a Manx and I loved him desperately, 653 00:40:39,760 --> 00:40:42,960 Speaker 1: and it was like living with a really fabulous drag queen. 654 00:40:43,280 --> 00:40:43,760 Speaker 2: Oh. 655 00:40:43,760 --> 00:40:45,239 Speaker 1: It would look you up and down and be like 656 00:40:45,280 --> 00:40:46,920 Speaker 1: you're wearing that today? Like chess? 657 00:40:47,120 --> 00:40:53,839 Speaker 2: Yeah, the goofiest, sweetest but also slightly attitudinous. Yeah. So 658 00:40:53,880 --> 00:40:56,759 Speaker 2: I knew that these discovery tours existed in the Assassin's 659 00:40:56,800 --> 00:40:59,600 Speaker 2: Creed games. I have never actually checked any of them 660 00:40:59,600 --> 00:41:03,560 Speaker 2: out on my games. I see them there in the menu, 661 00:41:03,800 --> 00:41:06,680 Speaker 2: I see that there are achievements for doing them. I 662 00:41:06,680 --> 00:41:08,520 Speaker 2: have not actually done any of them. I did not 663 00:41:08,719 --> 00:41:12,960 Speaker 2: know though, that they were also used in museums and 664 00:41:13,280 --> 00:41:19,880 Speaker 2: educational centers to like add another element to the educational stuff. 665 00:41:19,920 --> 00:41:22,839 Speaker 2: I think that is pretty cool. So thanks so much 666 00:41:22,880 --> 00:41:25,839 Speaker 2: for this email day. If you'd like to write to us, 667 00:41:25,880 --> 00:41:30,000 Speaker 2: we're History podcast at iHeartRadio dot com. We are on 668 00:41:30,080 --> 00:41:32,680 Speaker 2: social media at Missing History. That's where you'll find our 669 00:41:32,719 --> 00:41:36,799 Speaker 2: Facebook Twitter. It's not even called Twitter anymore. I don't 670 00:41:36,840 --> 00:41:37,920 Speaker 2: know why even say it is. 671 00:41:38,000 --> 00:41:38,239 Speaker 1: To me. 672 00:41:38,960 --> 00:41:40,600 Speaker 2: I think it's always Twitter in my heart. 673 00:41:40,800 --> 00:41:43,520 Speaker 1: I refuse to acknowledge. 674 00:41:44,760 --> 00:41:47,319 Speaker 2: And you can subscribe to our show on the iHeartRadio 675 00:41:47,360 --> 00:41:50,400 Speaker 2: app or wherever else you like to get your podcasts. 676 00:41:55,640 --> 00:41:58,760 Speaker 2: Stuff you Missed in History Class is a production of iHeartRadio. 677 00:41:59,080 --> 00:42:03,719 Speaker 2: For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, 678 00:42:03,840 --> 00:42:05,840 Speaker 2: or wherever you listen to your favorite shows.