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Welcome to “Should I Call a Doctor?” The podcast where we dive into trending health topics to separate fact from fiction. We bring in experts to talk about all things health, to empower you with knowledge and answer your questions hosted by Inova Health.
0: Welcome to, should I call a doctor,
the podcast where we dive into the questions you have about your health and
today's trending health topics to separate fact from fiction.
I'm one of your hosts, Dr. Sam Glee, an internal medicine physician at Inova.
1: I'm Tracy Schroeder. I lead communications for Inova.
Dr. Sam will give you the clinical perspective while I ask the questions that
keep patients up at night. We're excited to welcome Dr. Rebecca Colman,
who leads Innova's efforts in breast cancer screening and prevention at the
Innova Severe Cancer Screening and Prevention Center.
She'll share what every woman should know about screening, early detection,
family history, and risk,
and highlight some of the latest advances in research and innovation.
She conceived,
launch and serves as the chair and executive director of the Innova Civil Cancer
Screening and Prevention Center, a groundbreaking facility in northern Virginia,
that central, that centralizes risk-based cancer prevention, screening,
lifestyle interventions, and genetic testing,
and is part of a Nova Shark Cancer. Rebecca, welcome. Thank you.
Thanks so much for having me, Rebecca. Yeah.
Talk about where the idea for the Screening and Prevention Center came from.
It's one of the only one in this region, one of the few nationwide,
and something that I think really, you know, scratches an unmet consumer need.
Yeah. Um, well, I have to admit, it wasn't my brainchild.
It was a brainchild of, um, Dr. Deacon, Dr. John Deacon,
as well as our benefactor, Paul Seville.
They were talking about one way to be innovative in this area and in this space,
and decided, you know, based on personal experiences that they had,
um, wanting to figure out if there are better ways for us to be screening the
general population. And they came up with this prevention center idea,
and I ended up being fortunate enough to be able to serve here as the executive
director. How much of how the center is structured and what it,
what sort of cancers it screens for is, is because of your vision and direction.
Yeah. Um, so I started at Inova four years ago, um,
with this position when it was just me. Um, and so the,
the clinic was a shell, um,
and we had to decide how we were gonna build it out.
And we just decided that there were gonna be three core principles
or, um, guides that helped us develop the program.
And one was a clinical guide, the next was research,
and one was community outreach.
And those were the three kind of pillars that we started building from its
inception. I started hiring help because I couldn't do it all on my own.
Um, as a breast oncologist, I started seeing patients back then on my own,
but we really were only seeing breast, um,
and women that were at higher risk for developing breast cancer,
not who already had breast cancer. So, um,
so that practice started around December of 2021.
And then as we started talking to other partners at
Inova, other members of our faculty and and staff that are seeing
other, um, specialties,
we found a co co, sorry, a cohort of, um,
providers that were very interested in cancer screening and prevention.
And so we utilized all the resources that Inova already had and brought them
into one center.
So what we started doing was bringing them down to rotate in Seville to
do the screening part of what they did.
So we have a GI medical oncologist who had a passion for pancreatic
screening, Dr. Ray Wadlow,
and he started a pancreatic screening study as well as a clinic for pancreatic
screening in Seville. So we kind of created this, um,
you know, this, um, area for growth in,
in cancer prevention and screening. But what e evolved was, um,
we started seeing patients that really wanted to just be proactive with their
care.
And then we started seeing patients that thought that they might be at higher
risk because of family history, et cetera,
or people that already knew that they're at high risk because they had already
done genetic testing or somebody in their family had been diagnosed and they had
a mutation. Um, so,
and what has now happened is that we have been,
um, so pleased that there's so much interest in cancer prevention,
that we realize that we need to democratize what we're doing. Mm-hmm. Um,
that, you know, in a, a cancer scre screening space,
we really need to drive what's happening across the system from a general cancer
screening and prevention and not have everyone necessarily have to come to our
center. So we are working on that piece now as we, I,
I feel like take state, uh,
phase two of the civil screening and prevention
approach. Yeah. From a genetic counseling perspective and everything.
So we've been working, you know,
as a program on higher throughput ways of managing patients.
So one example is we have our genetic counselors who instead of doing
individualized counseling, which they still can do,
we started a group genetic counseling session. Um,
so all of our genetic genetic counselors do group sessions for those who want
it. And it's usually about five or six patients. Um, in one session.
We just had one this morning and they hear from the genetic counselor
about the pros and cons of genetic cancer.
And let me just say this is just cancer genetic counseling and testing. Yeah.
Um, the pros and cons and what are the potential results that could come out.
And, um, and they have this, um,
ability to generate a lot of conversation because maybe you didn't think of a
question, um, but somebody else did and asked it.
So it actually has been a very nice model for, um,
going through that process.
We've gotten a lot of positive feedback of doing those group sessions.
And then at the end of the group session,
the patient's brought back into a room privately so they can go over any
specific questions that they want to address with regard to their family before
they have genetic testing. So, um,
we have increased the throughput of genetic counseling because we don't have the
genetic counselor repeating over an hour or session one-on-one unless they,
again,
there are certain individuals that want that and we absolutely provide it,
but for most individuals,
they actually like the group session again because they're hearing from other
people that might have other questions.
And so it's thoughtful of you guys to think about like,
here are some of the aspects we can kind of do in a group and we can see more
patients.
And then here are the things that need to remain one-on-one from a patient
privacy perspective. Yes. And of course results all given individually. Yes.
Um, and you know,
one of the unique things about Seville is that we're able to follow those
patients longitudinally. So on the back end,
so we use the genetics as kind of a risk stratifier, if you will,
but there are other things that we do in the visit after they get genetic
testing to risk stratify them and decide if they need to be following in seil or
they could go back to their primary care physician or some combination of the
two. Um, so we see a lot of patients that's,
that don't have a genetic predisposition,
but we still think are at increased risk for cancer and we'll continue to follow
them. So is genetic, uh, testing, is that where they sort of,
is that the entry point to Seville start there and then we'll decide if you need
breast or lung or pancreatic or you know, what others, other,
other screening tools or tests you might need?
Or is that not the right place for everyone to start? Yeah,
that's a great question and it's something that our new patient coordinators
will talk through with patients when they call. Um,
if they have a family history that's suggestive,
we usually like them to see genetics first because it generally is the most
informative thing that we can do. Um,
if we don't think they have much or they have another concern that they're
coming in for, we'll see them. And once we see them,
we could always send them back to genetics if we feel like it's appropriate. Um,
so, and if they're just not sure we'll see them.
We do generalized risk assessments and inevitably, like I've been asked,
are there people that we can eliminate from our patient population?
I'll tell you that everybody has something like everybody.
And the other thing that's kind of unique about Seville is that we know
that lifestyle matters a lot with regard to cancer risk.
40% of cancers are preventable with lifestyle intervention alone.
So, um, I'll tell you that the majority of people that we see,
even if they don't have a hereditary cancer risk, have, you know,
a metabolic cancer risk. Um,
and we do have the infrastructure to manage that as well. So we have region, uh,
we have free dietician support, we have free health coaching that we offer,
and we also have access to a medical weight loss specialist, um,
who is embedded in our clinic every other Friday.
And that I could hear that people, people listening to this,
everyone would raise their hand and be like,
I have lifestyle factors that probably predispose me to a cancer risk.
Like should I be signing up for this? So from a metabolic standpoint,
if they're, if that's their main concern, they don't have a family history,
any other cancer risk concerns,
this is absolutely something that could be managed by their primary care
physician they should be addressing with their primary care physician. Um,
and there are a lot of resources out there at a Nova, um,
for help with weight management. Um, so I would definitely encourage that, um,
if they're coming in for any other concerns in addition to lifestyle, I think,
you know,
that's kind of when we trigger the Seville consult mm-hmm . Um,
we're doing very little advertising for a reason. 'cause we've had an, you know,
anywhere between a six and nine month wait list since we've opened. Um Oh, wow.
Yeah. And we do prioritize patients that need to get in for, you know,
if somebody was identified to have a mutation, we need to get them started. We,
you know, we can restratify them, but um,
in general we have a wait list because of interest.
So let's dive into breast cancer that you mentioned.
That's the place you started when this, when this first opened. So I think,
you know, tell us what the latest is in thinking when it comes to breast cancer.
Has the research evolved? I mean,
I know after a certain age it's mammograms every year.
Are there other risk factors for breast cancer that, yeah, so, um,
you know, breast is an interesting
specialty because it is something that's evolved, you know,
over the course of my career tremendously over two decades. Um,
and guidelines are, um,
have changed and are sometimes disparate. Like they don't always agree.
And there's, I feel like in the general population,
a lot of confusion about breast screening and what to be doing and when to be
starting and how they should be screening. Um,
and I get these questions all the time from women that are healthy, um,
from when I go to family events, you know, like right.
It's on everyone's mind 'cause they're getting inundated with it,
but they really don't know how it applies to them. Um,
so what I generally say, and this is kind of my mantra,
is that women should be able to talk to their primary care provider,
whether that's, um,
a family practitioner or an OB GYN about what their potential risk is.
Um, there are tools to assess cancer risk,
especially specifically breast cancer risk.
And a lot of it is dependent on family history, um, hormone exposure,
um, those kinds of things. So one that we use the most is called the cusic. Um,
and that's a mouthful, but it's just, uh, the other name for it is Ibis.
And sometimes when women go to a breast imaging center,
they'll actually run that, but women who are 30 don't get that opportunity.
Right. So they can ask for, you know,
an assessment from their primary care provider or their OB GYN about what they
think their breast risk is and when they should start screening.
So it does take a woman to be a little bit proactive about it because they might
not be thinking of it if they don't have any family history,
but they might be at increased risk for other reasons.
But when we were growing up, you would get those little things to hang over,
like the shower door and stuff to like remind you to do self exams. Yeah.
Is that still a recommended practice? That's a great question. Um,
no Oh.
0: Interesting. As a physician, I, I, if someone asked me, I'd be like, yes,
I think that's still a good practice. I mean, see that, but.
1: I mean, do I recommend it? Sure.
I mean I definitely feel like women should be breast aware,
but what they found was it didn't necessarily help, uh,
increase the uptake of cancer, you know? Yeah. Finding a chronic cancer.
0: Like it shouldn't be what you're grounding your correct.
Like reliance on finding cancer. Well, and.
1: And the side of it is that it causes a lot of anxiety. That's right.
And women's for us are really lumpy when you're young,
they're really complicated. So that exam can be very anxiety producing. Yeah.
Um, so I mean,
they should be seeing a clinician who should be doing clinical breast exams. Um,
they should know what in general they feel like and know what abnormal feels
like. Um,
they should be looking for red flags like nipple retraction.
So if the nipple starts pulling in,
if they have a rash on their breasts that's not going away, um, you know,
con general contour changes know what they look like.
So what I advise women is just to look in the mirror once a month,
generally a week after your period to just see what they look like,
know what they look like, um, and if anything changes to let somebody know.
0: And so for, that's very helpful. And,
and I know this is tricky because it's probably also asking a guideline
question, but would you say, listen,
any female of any age or after a certain age,
should a minimum have these questions asked to them by a physician,
or they should ask their OB GYN or primary care physician as young as
30 or 25 or whatever.
So you at least have a preliminary angle on, okay, you know what,
you're somebody who's probably gonna fall into the guideline,
the general guideline category. You know, I.
1: Think there's no absolute, um, I would say, you know,
we start screening our,
our guidelines for screening mutation carriers change usually at age 25.
So for in particular for a b, rca, A one or b rca, a two mutation carrier.
So if you have a family history that's really suspicious,
you really should be asking that question early in your twenties and most of the
time somebody else has tested in the family and you're finding that out. Yeah.
So without a family history,
I think 30 is a good idea to start talking about it. And what does that mean?
Um, you know, if somebody was diagnosed with breast cancer, let's say at 70,
probably not in their family,
but it's probably not gonna change screening for them,
we'll probably still recommend starting baseline screening at 40.
If somebody was diagnosed at 45,
we might take a closer look even if they don't have any known genetic mutation
in the family. And even if that person was a second degree relative,
let's say dad's sister was diagnosed at 45,
that makes us pay a little bit of attention.
Generally the rule is for screening to start 10 years before
the earliest diagnosis in the family.
0: And do you define family? 'cause you just said dad's sister as immediate family.
Do you define it as.
1: Blood relative? Yeah, sister. Right. Thank you for making this point.
'cause I I.
0: It's a, it's an a I wanna screen.
1: This one. The roof toss. Yeah. Because both sides of the family matter. Yeah.
So you can inherit risk from both your paternal side as well as your maternal
side moms or that side. Um, and so both sides matter and a lot.
0: So, but that brings up another point, which is you're,
you're saying two things there. One is both sides of the family matter,
but by definition it's also not just immediate family. Right?
So obviously we're not talking about dad or,
but that it's not merely sibling or parent.
There is an extension beyond that you take into account with family history,
whether it's grandparents or siblings or,
and maybe is that a general mantra that you would say applies to most cancers?
Or is this unique to breast cancer?
Because some of the mutations that you're talking about?
1: Um, no,
I would say most of the cancers that we pay attention to from a hereditary
perspective are what we call solid tumors. So those are breast, ovarian,
uterine, pancreatic, melanoma. So cer certain skin cancers,
um, those tend to be heritable prostate, I'm leaving out some. Um,
so, uh, if we see a pattern of any of those in a family,
we pay attention. 'cause a lot of, uh,
patients just think if I don't have a family history of breast,
then I'm not at risk. But maybe dad's side is all men.
0: And they have another solid tumor.
1: Or even nothing. Yeah. Because men can mask a mutation,
not develop cancer until later in life or not at all.
And then we don't know interesting that the next generation's really at risk.
Yeah. So if it's a, what we call a male dominant family, um,
or a limited family structure,
so less than one woman below the age of 45 or
above the age of 45 without cancer, then we need to pay attention to dad's side.
That's actually a criteria for genetic testing.
The other scenario that we see not infrequently is, um,
patients who are adopted and they don't know their family history.
Now their genetic testing might not be covered unfortunately. Um,
but we do still, still feel strongly that they should consider it. Um,
and let me just talk a little bit about the genetic testing because that has
changed tremendously. So when I got into this game a long time ago, um,
we were just testing for BRCA one and BRCA two and, um,
and that test was $4,000.
So if you do not meet specific criteria,
you are asked to fork up $4,000 to, to get the genetic testing done.
After about 2013,
these other labs to come and start offering what we call
panel-based testing, additional genes to be tested. Um,
and now, um, between that, uh,
competition as well as the fact that our technology has gotten so much better,
the most that an individual will pay out of pocket for genetic testing is $250.
0: And they would get a panel.
1: A panel of usually, you know, over 70 genes.
0: And are so.
1: Much more accessible.
0: Much more accessible.
Are you getting more access more of this covered by insurance now.
1: Too? Yes. Um, the criteria have expanded tremendously, um,
understanding that the syndromes are more than just breast and ovarian. Yeah.
They include all those other cancers that I mentioned. So talking a little bit,
um, mammograms obviously being the number one screener for breast cancer,
are there other breast cancer screeners? So, um, fairly recently,
the FDA has, um, started to require that, uh,
imaging centers provide information about breast density on the mammogram
report. So after a woman has a mammogram, they get a copy of, um,
a basic overview of what their mammogram showed. Um,
but they also get information about their breast density. And, um,
they do that because we know that certain women with extreme breast density,
the mammogram is not always as helpful as we'd like it to be.
And we generally start talking about using supplemental imaging. Um,
and so we wanna empower the patients to know, to ask their providers,
look at this mammogram, do I need to be doing anything else?
The problem is that once that started happening and women started finding out
about their density,
it was before we had clear guidelines about what to recommend Oh.
For women with dense breasts. Huh. So that's why there's so,
so much confusion and we see a lot as breast specialists of people being sent
from their primary care providers or GYN saying,
we're not sure what they should be doing,
or we are sure what they should be doing, but we can't get the test covered.
So, um, so it is, we're.
0: Still in this state right now. Yeah.
1: Unfortunately.
0: . And how much of that is because there isn't compelling evidence yet,
right. Versus we have the evidence but the insurance companies aren't bought in,
so they're not covering it. You know what I mean? Where are we on that journey?
1: I mean, evidence takes a long time to generate,
especially large population based evidence in breast cancer risk and screening.
So it's, it's, you know, the evidence is lacking, uh, uh, lagging behind. Um,
we have a lot of evidence in high risk individuals of what to be doing
for screening. We know that MRI helps, um, detect cancers earlier. Um,
and so we definitely know in the high risk population,
and most guidelines are pretty uniform about this,
that we should be adding MRIs, supplemental imaging. However,
if somebody's at average risk with dense breasts, what do we do?
Not necessarily gonna be approved. And what is the,
I've heard MR I've heard ultrasound, I've heard mammogram. Yeah. What are the,
how useful is each of those tools?
Or is it really the combination of them that gives you the best picture?
Another great question. Yeah. So mammograms are, uh, well,
I'll just say all the modalities are evolving.
So standard traditional mammograms used to be on plain films. Um,
now they're digitalized and now they're, we, it's added tomosynthesis,
which helps us actually eliminate some of the background noise. Um,
and we can see the images better.
So just the regular mammogram has gotten better. Um,
but for women with dense breasts and the code words are kind of
heterogeneously dense or extremely dense breasts,
we do feel like perhaps mammograms not sufficient. And,
and the reason being is that, um, mammograms, um,
in order to see a mass, which comes up as white, we need a darker background.
And women who have dense breasts, the fibrous tissue comes up as white. Mm.
So it's like, a lot of it can be tricky, right? So, um,
so we need something that differentiates that. So ultrasound can help us.
Ultrasound actually looks, um, because if we see masses,
they can determine if they're just CYS fluid filled,
or if they're actual dense masses that need to be evaluated further.
So ultrasound is, is probably the least helpful of everything,
but is better than mammogram alone. Mm-hmm . Um,
there is a evolving literature about, um, contrast enhanced mammography.
So using iodine, like, so the,
the contrast that we get with cts, uh, CAT scans, uh,
injected and gives us that functional aspect of the
mammogram to detect things that a plain mammogram wouldn't. Um,
right now these are not accessible everywhere. It does, you know,
require a dye and some people are allergic to that diet or don't wanna get it.
Um, and right now the guidelines are to use it if mammogram,
I'm sorry if MRIs are contraindicated.
So I would say the gold standard for women with high risk, um,
conditions like hereditary risk, um,
we should be doing MRIs as supplements. Um,
for women who don't have high risk, you know,
still the gold standard would be m MRI for dense breasts. Um,
but if it's not available, it's contraindicated.
We can look for a contrast enhanced mammogram.
0: Can you tell us very quickly about the mobile screening that you guys do?
1: Absolutely. Yeah.
So when I spoke to the pillars at the beginning of our conversation,
community was always, um, our focus from the beginning.
We wanted to be able to provide everything that we provide in this very
specialized center, um, to be out in the community and accessible.
Um, we realized early on that women who were underinsured or uninsured did not
have access to mammography. Um, even those who had insurance,
um,
and just were not great at accessing the health system could not get
in to get a mammogram.
So we feel like this has been a game changer for a lot of the partners that we
work with. We work with community partners, we work with FQHCs, um,
and women just now are getting the mammograms that they need. Um,
so our unit,
our mobile screening unit has a mobile mammography as part of it,
but we also have an area to do pap smears.
We actually have an exam room so we can offer additional supplemental screening.
The other big piece of it is that we do a lot of research, um, at Seville,
kind of looking at novel types of screening.
We didn't get to talk much about it,
but there are blood tests that are in developments looking for multiple
different types of cancer in the blood,
the types of cancer that we don't have good screening for,
like ovarian and pancreatic. Um, and these are really promising tools.
Um,
and so we are doing active clinical trials in Seville using these,
these, uh, blood tests. Um,
and one of the things that we felt strongly about is that we wanna be able to
offer that research to the community as well.
It's very important that everything that we're offering at Seville,
again gets provided to the community. So.
0: You're doing this in the mobile screening? Mm-hmm . Yes. Wow. Yeah.
I, yeah, I can't agree more.
1: Dr. Kaman,
thank you so much for talking with us today and sharing so much helpful
information.
Screening and prevention is such a great topic and a great service that you do
provide to the community, so it's really awesome.
2: To have the opportunity to share it.
1: Thank you so much for having me.
2: Thanks for tuning in. We hope you enjoyed this episode.
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