I think we'll probably and good evening.

>> Thank you so much for watching HealthLine on PBS for it.

Wayne, I'm Mark Evans and for Jennifer Bloomquist tonight.

Thank you so much for watching tonight a very, very important topic especially for women and it does affect some men.

We're talking about cancer and mammograms, the early detection saving lives and with us a very special guest back after about a year and a half without seeing us.

But it's wonderful to see it's Dr.

Patricia Clark.

She is a surgical oncologist and I understand the last show we had was very, very interesting and very informative and very important.

>> So we're so glad to have you back.

>> Well, thank you for having me.

Absolutely.

And before we get started, Doctor, I want to go ahead and remind everyone we have a couple of ways that you can call in with your questions or concerns and the phone numbers will be on your screen throughout the program.

>> Number one is you can just simply give us a call from your cell phone and you can let us know what question you'd like to ask where you can stay on hold for just a short while until we get to you and we'll bring you on the air with your question live the other way is the good old texting method.

>> So wherever you are from give us a text and that number is on your screen as well.

Ask your question and we'd really appreciate if at least you give us our location you're calling from and your first name so we can address in do a nice shout out to your town or city from where you're calling.

>> So let's go and get started.

Mammograms first of all, a little history.

>> How long have mammograms been around?

Oh no.

I think the first question all right.

>> And we talked a little bit about what we were going to talk about in the green green room.

>> That question just popped up in my head because I was wondering how people were diagnosed before mammograms.

>> Now you know, that's actually a great question and you'll hear people talk about operating on cancer and that spreads it because you opened it to air and what used to happen before mammograms, before the X-rays all of that is by the time a cancer was large enough to be detected it had already metastasized.

>> So we would go and do surgery and then the patient wouldn't do well.

They may die shortly afterwards.

So that's how that myth sort got planted in people's brain.

OK, and then you know the mid 20th century we start getting more of the mammograms and that type thing and then more recently mammograms are widely widely available now.

So our survival rates from say the 1950s until now are extraordinarily improved but we detect these cancers when they're very small before they've had a chance to spread and that's driving a huge part of the survival.

>> I see.

I see.

So probably since what the maybe the 60s or 70s mammogram mammography has actually become fairly popular.

>> Yeah.

And utilized quite quite a bit .

>> Yeah.

And we were using them in the in the 60s and 70s but they weren't as widely available as they are now and then the mammography technology has improved quite a bit.

>> It used to be just 2D mammograms which you can still find that some places but in the United States the standard of care now is a three d mammogram so that has a much better detection rate and then the other thing is it doesn't misread as often.

>> So are we talking about radiation methods or is it more of a CT scan?

>> This is the 3D mammograms take pictures like separate slices through a sort of like a CT scan.

OK, it's not an actual CT but CT scans work by imaging slice by slice by slice so the tomosynthesis to the 3-D mammogram does the same thing.

>> All right.

And also just to stress the importance of this program tonight I want to talk about some facts and figures.

>> You have any stats you can share with us?

There's a couple of them I think are pretty important.

We I hear a lot of people that are a little reticent to get screened because they don't have any family history of cancer and they just they're healthy.

>> They don't feel they're particularly at risk.

But one in eight women are going to get cancer one and one in eight .

>> So the average 40 year old walking around has over a 13 percent chance at some point in her life she will get cancer.

>> Oh my yeah.

Oh my yeah.

Well and then I also read which I'm hoping was people like you professionals like you we can get this number skewed down a bit but it's projected about a little more than 42000 women in the United States will die of cancer this year.

We have in the United States well you have about three hundred seventy thousand women will be diagnosed with cancer .

That forty thousand those are not people who are who get cancer this year and then are going to die.

>> Right.

Some of our treatments our treatments are becoming much more refined and targeted to where we now have people living ten years with cancer and twenty years ago that wasn't happening.

>> OK, and I understand there's more than one type of cancer.

>> Are you able to there are so so we have some buckets that we sub classify the cancers into the majority of them are what we call an invasive ductal carcinoma arising from the mouth that and invading outside that and into the tissue.

We have some there like ductal carcinoma in situ which those are just stage Xeros those are cancerous cells confined inside of milk duct and as long as they stay there and they never go anywhere they can't hurt anybody.

>> OK, the problem is some of those are going to progress to become the invasive that has the ability to spread throughout the body.

We still don't know exactly which one of the ductal carcinoma in situ are have that capacity which don't.

>> We're honing in on it.

There are there are many subtypes like lobular carcinomas and metal plastic carcinomas when I think of cancer I my treatment algorithms sort of are based on this but cancer is a molecular problem.

Our DNA is mutating every single day, every minute if I go outside boom boom boom the sun's going to break strands of DNA.

We have genes that can fix all that broken DNA.

One of those genes is the bracket gene like Angelina Jolie had in her.

That gene was mutated in a specific spot.

>> It disabled it so she had an eighty seven percent chance she was going to get cancer sometime in her life after she had her children she actually chose double mastectomies to prevent that.

Yeah.

And these cancers in order to get a cancer you have to have a lot of mutations that are very, very critical pathways in that particular misbehaving cell for a cancer to occur it's got to be a hide from your immune system.

So most people with cancer or any type of cancer nothing wrong with their immune system.

The immune system doesn't even know it was there if the immune system did know it was there and the body couldn't repair the the defect in it, the immune system would have killed it.

>> You have to have mutations that allow the cells to grow uncontrolled and divide uncontrolled for a cancer to be able metastasize that may need a whole nother set of mutations .

>> So when we look at cancer now every single cancer has its own unique fingerprint and what's happening in treatment and covid actually help us.

>> What's happening is where able through testing to get more and more precise about the individual mutations that a person's cancers have and how to target our therapies to them .

I was I think I was telling you before twenty years ago if somebody told me I would be a surgeon no way back then I didn't like doing surgery because the surgeries were fairly crude.

>> We we would do a lumpectomy and just remove the tumor but we would never fix the defect that we made.

>> Everybody with a one centimeter cancer got chemotherapy B. Now we know almost none of those people needed it.

We took everybody's lymph nodes out which could lead to arm swelling.

Now women 50 years old and over we look at every one of them to figure out if we even need to do that anymore.

>> Oh wow.

That well, we used to if there was a lymph node that was positive, people got chemotherapy.

Now we do genetic testing of the tumor itself to determine whether you need chemotherapy or not.

>> Oh, I see.

And I get a lot of people that are afraid they're a little afraid to be screened because they're afraid of what they might find right.

>> Our most aggressive cancers if we can find those small enough you don't need chemotherapy.

>> So the chemotherapy has to do with the biology of that tumor and its own mutations.

But this is why I'm sort of here to champion this early detection screening.

We've reached a point where for most women this cancer treatment is kind of a blip in their lives and they go on, you know, some of these cancers unfortunately that's not the case and we can get a tiger by the tail with some of them.

>> Right for most women.

Well, unfortunately we only have half an hour.

So I would we would go down each one.

I see more than a dozen different types of cancer.

>> What would be the most common that you come across the most common is the invasive ductal carcinoma massive.

And when we look at the invasive cancers we test for three different proteins on them.

Do they have receptors for estrogen?

Do they have receptors coating them to bring in progesterone and this harto new protein and most of these cancers will have estrogen receptors on them which is nice as a target to keep people from recurring if the estrogen receptor positive tumors are usually a little bit more benign, they don't spread as quickly.

It's not uncommon to see somebody who's had one of these cancers for two or three years and it still hasn't spread if they don't have any of those proteins those those are the bad actors that have the ability to mutate and not mutate but they have the ability to spread and those are the ones who need more aggressive treatments.

>> All right.

And whether they're the most common or some of the more rare cancers, are they all detectable through mammography?

>> Actually they're not.

So everybody's nightmare and I think everyone has an anecdote where they've heard of somebody where they got a mammogram and they didn't find it the invasive lobular carcinomas those those don't form a nice solid tidy tumor that's easy to see the cells sort of line up in a row.

>> So particularly if somebody has dense tissue those can be missed.

>> And when I find those a lot of times a woman can feel a lump or she says her is changing.

>> She may have pain which pain is not common with cancer.

Most cancers are pain free but usually the woman has found has found something and then I have other imaging other than a mammogram if I if I have a suspicion or something isn't lining up exactly right, I can do something like an MRI and samurai's are specialized where we have a special coil but we give an IV dye and the cancerous cells pick up the IV dye at a different rate and hang on to it longer than a normal cell.

>> So we also do this for extremely dense tissue or .

They're are very complicated with lots cysts.

Where it's hard to find is there's something bad happening there or is this just normal sort of chatter?

But anyway yeah we we additional imaging modalities for these ones that are harder to detect and an MRI is not something that somebody should just go do just in case though, right?

>> Well, I'm several questions regarding the MRI I'm sorry the mammogram process but I want to skip ahead here who should be getting these mammogram screenings so you'll hear a little bit of controversy with different guidelines but all the major like the American society, surgeons, the American College of Radiology, everybody age forty on should have an annual mammogram.

>> And then one of my particular interest is when should people stop?

>> And there are some guidelines that say after age 70 stop.

Well, our patients are living to age 90 and still driving their car.

>> That's 20 more years the age 70.

>> That might have been true on studies that were done 30 years ago.

If somebody has less than ten years of life left, they can consider stopping.

But I see a lot of women come in actually in their eighties and they may to be in their mid eighties and they have cancer.

>> Nobody check them since they were seven years old.

If you are healthy, keep getting the mammograms and how often?

>> Once a year.

Once a year.

Once a year and then there are other high risk people.

If somebody has a family history of cancer, we recommend they start the mammograms ten years before the age that the the youngest person with cancer.

>> So if if mom had cancer at age 40 then they should get their first mammogram at age 30 .

>> We don't do mammograms on women in their 20s and one of the reasons is the tissue is so dense that it's very hard to interpret everybody at age twenty five though should have their primary care doctor do a risk assessment on them and see what their family history is.

We're actually seeing increased rates of cancer and even in young women nowadays we're not sure exactly what that's coming from but there are several things that we do know drives that one of them is women are delaying childbirth quite a bit.

So there used to be everybody had the children when they're twenty right now they're thirty thirty five.

>> So the longer you wait before you have your first child that increases the risk and then the other thing that increases risk is obesity and we have you know, quite a weight problem these estrogen driven tumors fat cells make estrogen so that that's one of the predisposing factors and then there are others such as exercise, you know, lack of exercise.

>> There can be environmental things.

Some people may even have some genetic just little genetic quirks in themselves or their family that is not necessarily a gene that we pick up with genetic testing.

>> All right.

We do have a test coming in.

>> It's from Sophie and she's from Auburn.

Thank you, Sophie.

She's saying my father and my sister both had mastectomies with recurrent cancer on their Mastec side several years later.

I guess my question is people with bilateral mastectomies, how are they screened?

>> How are they going forward since it is possible to redevelop the cancer after that mastectomy?

>> So that is a great question really is when we do a mastectomy generally the the subcutaneous tissue we remove all the tissue so all we're left with is the skin and usually no more than a half an inch of subcutaneous tissue because there's no deep tissue there if somebody develops a recurrent cancer even the size of a pea or a peanut, you will feel that so we don't do any imaging and somebody that's complicated and has had multiple recurrences or something that may be a different story but the the average normal person with a mastectomy you don't need to do imaging.

You can do a physical exam and this is something people can even do in a shower where you just rub rub the hands over the chest and if you feel a knot or a nodule then you come in to the surgeon or the radiologist will ultrasound it will biopsy it and so we can detect recurrences when they're still very, very small after a mastectomy.

>> And she hit on a very good point.

Men can actually get cancer as well and so do men get mammography so men don't require screening mammography?

Is this family history when you have a man with a cancer and another family member with a cancer such as our caller, those are the people that we worry about having a genetic mutation like this Bracher mutation men that have a mutation like that they absolutely should be screened.

>> We only have about fifteen hundred men a year in the United States develop cancer.

>> So we see quite a few of them here with Manam cancer.

What generally will happen is they'll be a little bit of tissue right behind the complex.

So if that starts getting hard it starts getting red, it starts getting scaly, something becomes abnormal there.

>> That's when they should absolutely check it out.

All right.

Very good.

Glad we address that.

Another text coming in from James in Fort Wayne How hopeful are you for a future of the cancer treatments?

>> That's that's another great one.

Yes, I am very hopeful.

>> But if we go back to his question, you said something about are we going to can we find a cure in the next 20 years?

Yes.

No, we will never find a cure because the cancer is not a single disease.

>> The cancer if you figure out how many millions of of molecules make up the DNA molecule that is in every one of our cells and how many mutations can happen in there?

Every one of these cancers has its own unique fingerprint so there's not a cure.

If we were going to cure cancer we would probably be immortal.

We would have to have so much control over every single chemical reaction that happens in our body and every little alteration and just us wearing out so so there's not going to be a cure what there is going to be and this is why I'm so excited about my profession as we understand more and more of the genome and molecular genetics and immunotherapy and all these things we get more and more precisely targeted to where we can knock these cancers out.

>> You know, Jimmy Carter was a great example of this.

>> Jimmy Carter had melanoma.

Yeah, he had melanoma that when I started my career that was one hundred percent fatal.

But they found the molecular key to his particular melanoma boom.

>> Yeah.

Going to be one hundred years old.

He lived to be over one hundred years old and that's happening some of our most aggressive like the heart to nuke positive cancers.

This is a protein on them.

When I started my career that was one of the most deadly cancers you could have.

Now if somebody comes in with that, we give them chemotherapy right up front.

I don't even operate right away.

We give that chemotherapy by the time we're done with that chemotherapy between 60 and 80 percent of those patients don't have a trace of that cancer left.

I just go in and do a little surgery and take out where the biopsy clip was approved.

It's not there anymore and those patients do fantastic.

Well, I put one woman came to me she was over one hundred years old with that cancer and I put her on that chemotherapy and it didn't even knock her down.

>> Wow.

It's that so so you know the future as long as we can keep research, as long as we will fund research in the United States, a lot of these cancers we're going to be able get control of .

>> I'm so glad to hear that another call coming in looks like Sophie from Auburn and we'll bring that question up.

But what if they have implants after a mastectomy?

>> How do you screen so the same thing with the implants with the implant you've got you've got maybe a half inch of tissue and then you've got a implant under that most of the recurrences are going to occur and the skin or in that soft tissue less than five percent are going to be on that muscle behind the implant.

>> So we don't we don't need to screen after an implant and the implant actually stretches skin a little tighter to where any irregularity or lumps in there are even easier to detect.

>> All right.

And just for those who don't know or have never gone through a procedure, would you explain what someone can expect from that experience as doing a mammogram?

Yeah, so so there's generally the size of a big exam room and there's an upright machine in there and then the mammography machine has has two plates and yes, women get squeezed the the technologist will position the so that they can see all the way back to the chest wall because if you just get the front of the you may miss what's in back the plates will will squeeze down and then they have a pressure sensor on them to where they they're going to stop at a certain point.

And having been a veteran of multiple mammograms myself, I've had somewhere I happened to be tender that day.

I've had plenty others where I didn't that sort of an individual thing it should not be painful but as many women will tell you sometimes it's tender so sure.

And it lasts probably it's probably five minutes or so.

They take multiple multiple views and I know some people have some mobility issues.

Right.

A lot of times you can use a cane, you can use a walker and some of the mammography machines are even they're adjustable up and down to where even some women in wheelchairs will challenge them.

Yeah, when we have people that are completely prone that that can become a problem because we can't get them up close enough to that machine.

>> Right.

To get that done right.

>> Well we only have a couple of more minutes left and you've been so informative we truly appreciate it.

But if one wouldn't want the radiation, can they just have an ultrasound now so that we get that we get that question a lot.

So it's interesting that our three main imaging modalities are the mammogram, the ultrasound and the MRI and they each do something completely different the mammogram.

We can see a solid tumor on it.

We can also see calcifications and it calcification tells something died right there and that's part of the little scar scar that did so when we get into these ductal carcinoma in situ which are like the stage zero, those don't even have the ability to bring in a blood supply to nourish those rapidly developing or growing cells.

So some of them will die and we'll see the calcifications.

>> We can't see that on an ultrasound at all.

The only thing on ultrasound will show us is a solid mass.

Some of the lobular carcinoma we wouldn't be able to see that on an ultrasound.

>> Ultrasounds are useful if we're trying to figure out if we see something on a mammogram.

We were wondering whether it's solid or it's it's cystic or fluid filled.

The ultrasound will tell us that the ultrasound is pretty good at telling us the size of a solid mass.

It can pick up about four more cancers per thousand when you add it on top of a mammogram but it's absolutely won't replace it.

>> OK, if you have particularly more dense, are they going to need extra imaging?

>> So so that's a it depends.

So we have like four classification of density goes like ABCDE the most women actually have over 50 percent of women have dense so so it's normal it can make it hard to to tell if everything's white you don't know if there's a white mass hanging out and all the rest of that white.

So this becomes an individual thing.

The 3-D mammograms that we do now those are fairly good for dense tissue but the the patient's doctor or surgeon whoever may decide if somebody has very dense, some people will benefit from having an ultrasound added on top of that, particularly if they have a lot of fibrocystic changes and things just make things a little busy and cluttered then that's good.

The extreme density where everything's white it out those we will even look at with an MRI.

>> All right.

Well we thank you so much for being here are running out of time.

I want to remind our viewers you can watch this episode as well as other HealthLine episodes on our website and on YouTube.

Again, thank you to Dr.

Patricia Clark for being here and we hope to have you back again soon.

Oh, thank you very much.

All right.

Until next time.

Thank you for watching.

Good night and good