We Can Do Hard Things with Glennon Doyle - Early Detection, Mammograms & Breast Cancer Care with Dr. Rachel Brem

Episode Date: June 18, 2024

320. Early Detection, Mammograms & Breast Cancer Care with Dr. Rachel Brem Amanda shares an update on her recovery from breast cancer. Then, renowned breast cancer expert, Dr. Rachel Brem, joins the conversation to discuss the critical importance of early detection, breast density's impact on mammography, and when we need additional screenings.  Discover:  -The differing guidance on screenings and the truth about how often you should actually get screened for cancer; -Advice on what to say to your doctors to make sure that you get the screening you need and so that they can be covered under insurance; and -How to learn how dense your breasts are and what to do with that information.  On Dr. Rachel Brem: Dr. Rachel Brem is the author of No Longer Radical: Understanding Mastectomies and Choosing the Breast Cancer Care That's Right For You. Dr. Brem is an internationally known breast cancer expert who has been instrumental in developing and implementing new technologies to improve breast cancer detection. She is Professor and Director of Breast Imaging and Intervention at George Washington University, Vice Chairman of the Department of Radiology, and Chief Medical Advisor and Cofounder of the Brem Foundation. She is a Fellow of the American College of Radiology and the Society of Breast Imaging. Find more resources at The Brem Foundation Website: https://www.bremfoundation.org/  Check out Dr. Brem’s Book, No Longer Radical: https://www.nolongerradical.com/ To learn more about listener data and our privacy practices visit: https://www.audacyinc.com/privacy-policy Learn more about your ad choices. Visit https://podcastchoices.com/adchoices

Welcome back to We Can Do Hard Things. So many of you have been reaching out to us to check on Amanda and how she's doing. If you don't know, she was diagnosed with breast cancer. She came and did the update for us on that. And then she had a double mastectomy. She talked to us after that. And now she's going to give us the latest update as now we are many weeks past the double mastectomy. So we're very grateful that she's gonna update us and we're so grateful for all of your love and support and questions checking in on her. So hi, Amanda. Hello, G-bird and Abby.

Yes, everyone has been absolutely amazingly supportive. And it's, you know, when you think about one in six women will have breast cancer sometime in their lives, I guess it shouldn't be shocking that so many of the comments and feedback were, you know, that was me 10 years ago or that is me this week or that is my mom or, you know, all of it touches everybody. But the very, very wonderful news is that my pathology came back absolute best case scenario. There were no positive margins, meaning there's the part that they took out was clear of any cancer. So it wouldn't be touching tissue that remains in there. And they had five close margins.

And also they were able to do some diagnostics on the kind of cancer that was in there. And it was a very dumb kind of cancer in terms of like they can rate how aggressive it could be and how likely it is to spread quickly. And in other words, how smart and conniving it can be and mine was very foolish. So it was a slow moving situation and we thought originally that there might be a recommendation for some endocrine therapy, meaning because mine was progesterone and estrogen positive.

And so one thought was that if you block those receptors on the cancer, it's less likely to replicate quickly. But when we did the risk analysis of all of that, the risk that mine showed was so small that on balance they recommended just continuing with screenings and healthful living habits and that the mastectomies were all that we needed. So it is an absolute absolute blessing and joy and delight. And I'm very, very, very thankful for it. And the reason that it's such a good prognosis is because it was detected so early and it was early and treatable.

And so this is why I'm so, so thankful that we're having Dr. Brehm on right now, because her whole life's work has been to try to promote the detection of early detectable breast cancers in women so that my outcome can be other people's outcomes and it can be a great, you know, have your whole lives ahead of you. So she has been an innovator in that space and she's here to kind of break down all of what you need to know, the factors that go into risk, which types of people need which types of screenings, and what you can't

trust in addition to what you can trust. So I'm so happy that she's here because I believe those kinds of screenings are what saved me. The best news. The best news. And heart just so full for people who get different news. Just all of it.

Okay, well why don't we get going with Dr. Brem so we can give everyone in this pod squad who we love so much the information that they need to protect themselves and the people they love as best they can. Yes, I'll intro Dr. Brem. Dr. Rachel Brem is the author of No Longer Radical, Understanding Masectomies

and Choosing the Breast Cancer Care That's Right for You. She is an internationally known breast cancer expert who has been instrumental in developing and implementing new technologies to improve breast cancer detection. Dr. Brehm is professor and director of breast imaging and intervention at George Washington University, vice chairman of the

Department of Radiology and Chief Medical Advisor and Co-Founder of the Brehm Foundation. She's a fellow of the American College of Radiology and the Society of Breast Imaging. Dr. Brehm. Hi, how are you? Hello. So nice to meet you. You too. Oh my gosh, finally.

First of all, you know, I was listening to your podcast and it was released on the 14th and you said you were having surgery in a week so that you must be eight days out. How are you feeling? How many days out are you? You look beautiful. We actually put those pods out a little bit later than they were recorded. So I am now four weeks out. Everything is beautiful. perfect. I had amazing

recovery. I feel amazing. It's all very, very, very, very wonderful news. Awesome. We read your bio and all your credentials. And I'm just want to say how I started at saying how my prognosis is so beautiful and wonderful precisely because of the early screenings and the fact that this was so treatable because it was so early and how I'm so thankful for all of the work that you've done over the course of your career to educate people about what they need to do for a good outcome, which is to detect early. And I wondered if, before you give us all of this information that it is absolutely criminal that we don't already have, can you start with your story? Because I think it

is absolutely amazing that you saved yourself in the process of saving so many of your patients. Yes. I'd love to start with my story, but I also want to say that I'm thrilled that you're doing so well and that, you know, oftentimes one of the things that I've learned to really appreciate is the silver lining of the gray cloud. And so although I'm very sorry that you've had to go through all this and it's been an emotional roller coaster, physical roller coaster, but what a wonderful outcome that you're sharing your story with millions and educating, and you will absolutely be responsible for saving lives and there's nothing more noble than that. So, you know, thank you to Glennon and Abby and you for doing what you're doing.

And it's hard. I mean, I know it took me years to feel so open and transparent and vulnerable before I really was sharing my story as well. So thank you for what you're doing. I think my story is the story of, in some ways, the history of breast cancer over the past 50, 60 years. So in the 1970s, my beautiful, vivacious 33-year-old mother disappeared. And we didn't know where she went. She came back about three weeks later, and there was a spark that was missing.

We knew that something had changed. I was 12. I had a 13-year-old brother. I had a five-year-old brother. And we weren't exactly sure what had happened. It was several months later that we were told that my mother had had breast cancer, and we were told that she had six months to live. So, you know, fast forward, it was a precursor of what the impact of early detection is. And so she lived 44 years, you know,

not only did she get to raise us, she saw grandchildren and even great grandchildren. So I got to be a very early beneficiary of early detection. And as a 12 year old girl, I just decided that I wanted to change the narrative of other families. And it's important to remember that that was in the 70s. I'm an immigrant.

I was born in Israel. I came here when I was three. And I remember the first time I said to my parents, I'm going to be a doctor so that I can change that. And they said, that's ridiculous. I've never met a girl doctor. And they actually didn't like the idea at all. They wanted me to have what they had, which was a beautiful home and friends and family. And so, you know, I sort of plugged along, was very good at math and science, went to college. I went to college actually a year early on my high school dropout. So I went at 16. At 17, I met my husband. At 18, I got engaged. At 19, I got married. And my parents were so thrilled because they thought this madness of medical school would pass. Finally, she got it out of her system.

Yeah, right. So when I applied to medical school, they seemed shocked and not quite as supportive as I might have thought. But through their lives, they're not with us anymore, but through their lives, they had become obviously very proud and also shared this lemonade at a lemon approach. And so I went to medical school, I went to Columbia in the eighties, when that was the first time we saw that mammography

can decrease the death rate from breast cancer. It was the first, it was called the HIP study, the Health Insurance Plan of New York. And we saw that there was a 20% reduction in the death rate from breast cancer as a result of mammography. And in those days, mammography is nothing like what we have today. And so I decided, although if you would have said to me, do you see yourself as a radiologist?

I would have said, I don't even know what a radiologist is. When I started medical school, I wanted to be a pediatrician like so many, but I thought I really want to get on that bandwagon. I wanted to be part of that. So I trained in radiology at Johns Hopkins, stayed on the faculty. Then in 1996, I got tested for the BRCA gene. I remember saying to my husband, if I'm negative, I want to have a fourth child.

At that point, I had had three girls. And if I'm positive, I'm going to have prophylactic mastectomies. And there was no data at that point to show what the reduction in the death rate from breast cancer was. But I just wanted to change the narrative. By that time, my aunt had had breast cancer and my mother had had ovarian cancer. My aunt would shortly be diagnosed with ovarian cancer. And so I just decided I

wanted to change the narrative. So got a lot of various pushback from people, but I'm not a good listener when I'm helping and getting something done. So I decided to have a bilateral mastectomies, went around the country, decided what kind of reconstruction I wanted. And between scheduling that and my surgery, I was trying ultrasound equipment as part of my job, just to figure out which ultrasound unit to buy. And when I was scanning myself one evening, I not only figured out what ultrasound equipment I wanted, but also found my own breast cancer. So that was the first inkling that I was going to write a book because I felt so lucky. I felt so lucky. And I know that you shared that sentiment in your podcasts.

And the reason I felt so lucky is because I knew what I wanted. I had the information I needed and I couldn't even get my head around how complicated and difficult and daunting it must be for my patients when you tell them you have breast cancer. So I knew exactly what I wanted to do, but that's not the way it is for everyone. And so I went from prophylactic mastectomies to bilateral mastectomies with gorgeous reconstructions after nursing three girls, um, little saggy. I also had my ovaries out at the time because I really wanted to do everything I can to survive and raise my two nine year olds and 12 year old at that time. So I had, I started chemotherapy the morning after my oldest daughter's bat mitzvah.

And here I am 28 years later. It's amazing. It's amazing. It's amazing. Hi, I'm PJ Vogt here to tell you about my new podcast, Search Engine. Search Engine was one of the very best new podcasts of 2023, according to Vulture, Vogue, Time Magazine, and The Economist. We answer fascinating questions about business, tech, and history. Questions like, why are drug dealers putting fentanyl in everything?

Who should be in charge of artificial intelligence? How did ADHD medication get so popular so fast? Listen and follow Search Engine with PJ Voet and Odyssey Podcast, available now on the Odyssey app or wherever you get your podcasts. You talked about how hard it must be to not have the information that you need. And a lot of people who are going through this are relying exclusively on the information that's provided to them by medical

professionals. Can you talk to us about what the new task force recommendations are? And can you just walk us through what parts of those are not in line with what the most current research is? Because it is confusing to look at things from the government is passing down as this is our recommendation for you. You'd think that maybe that could be trusted, but it seems not consistent with early detection. Can you just talk about that confusion and where we land with it? So really, there's so much confusion about screening mammography. Every organization, every society has virtually their own different recommendations. And how can that be? So the

first thing that I'd really love the people listening to this to know is that I'm an example of that and you're an example of that, which is breast cancer is not a death sentence. We survive, we thrive, we grow, we find the silver lining. But early detection is important for a number of reasons. Firstly, survival is better. But secondly, the journey that a person has to go through to get to survival is much less intense with early detection. We don't talk about that enough,

what I call the intensity of care. So if you look at two women, one's diagnosed later, one's diagnosed earlier, and they both are cured of breast cancer, and we're so lucky that we have targeted therapy and immunotherapy and, you know, personalized therapy that someone with a slightly later stage cancer might also get cured,

but what they have to go through to get to a cure is different. So we can't just look at survival when we talk about that. And when we talk about screening, it's very confusing and you're right to use the word confusion. So the first thing that everybody should know is the death rate for breast cancer has gone down about 50% over the past 30 years.

And that's amazing, right? So half the number of women are dying today or twice as many died when my mother was diagnosed and not that far along from when I was diagnosed. And half of that is due to screening and half of that is due to improved therapy. So if you look at the American College of Radiology and the American College of Surgeons, they're really the ones that got it right. They say start at the age of 40 if your average risk and get a mammogram every year in order to achieve the mortality reduction, the death rate reduction that we've achieved.

Other organizations like the USPSTF just changed their recommendation from starting at 50 to starting at 40, and that's because the data is overwhelming that starting at 40 is the way to go. And in fact, a quarter of breast cancers occur in women 40 to 50. So if we're not screening that population, we're losing a huge opportunity to save lives. But they got that right. But then they said, screen every other year. And if you do that, you'll still maintain almost 90% of the mortality reduction that we've achieved.

But don't we have the right to get 100% reduction in the mortality? And we'll talk about why they say that. Then the American College of Family Physicians say start at 50 and get it every other year. And yes, you'll still save 80% of the women we save now, but why shouldn't we save 100% of the women? And what's more bothersome to me is that many of my colleagues and friends who are primary

care physicians come for their mammogram starting at 40, and they come every year. And then the American Cancer Society says, well, think about starting between 40 and 45. Definitely start at 45. Go to 54 every year, and then after 54, every one to two years. And the USPSTF says, as we said, start at 40 every other year and stop at 74. That is so wrong on a number of levels. First of all, the number one reason that they don't recommend annual screening mammography

is the harm. And the number one harm of mammography, which blows my mind, is the anxiety women are going to feel if they have to get called back for another picture to make sure they do or don't have breast cancer or even a needle biopsy to determine whether they indeed do have a breast cancer. It's so patronizing. It's ridiculous. It's disgusting because we do not live in the middle ages. We are empowered, educated women. We should have the right to decide if a little bit of transient anxiety is worth saving our lives. And it's just the most demeaning reason for not offering or encouraging women

to come for a mammogram every year. So is the real reason money? Yeah, exactly. Is that the purported reason? What's the real reason? Yes. I would have, I mean, there's, we get to save lives. Like, isn't that what we should be doing?

So, you know, there are air quotation marks, harms of mammography, and that's the number one harm. That's absurd. That gets me on my soapbox. We live in a time when women are empowered and educated and have to advocate for themselves. And never is that more evident than this. And then the other piece is stop at 74.

That is a horrible value on life. Studies have shown that older women who don't get screening mammography die of breast cancer more frequently. Grandma Moses didn't start painting until she was in her late 80s. I have every intention of continuing to contribute to the world in my 70s, you should only stop if your life expectancy is five years or less. So if you are average risk, you should start screening at the age of 40 every year until forever. If you are at higher risk, now that's someone like you, that's someone like me. We could talk about Glennon, whether she's in that category

now as well, because of the family history. And, you know, I heard on your podcast that there are multiple people in your family who had women cancers. So if people are at higher risk, they should start five to 10 years earlier than the age of your first degree relative to get a mammogram. And if you have dense breasts, you need additional screening, whether that's ultrasound or MRI is another question. And then finally, if you're at even higher risk, like someone from my family, and now you, your family, then you should consider getting an MRI every year because that's sort of the power imaging for finding breast cancer as you yourself found out. This is so helpful.

If you are average risk, go in at 40 and go every year for mammogram. Then we say, if you're higher risk, our higher risk categories, we either find out because we have dense breasts or because we have family history or because of a genetic testing genes. Would those be the three main categories that we would know that we were high risk?

Yes. And there are others as well. Some women who've had a previous biopsy that shows something called atypia and they too are in a higher risk. Okay. Have a much higher lifetime risk. But those are the primary risk factors that you need to consider. And there are online tools.

One of the wonderful outcomes of breast cancer is that I had the privilege of being part of a nonprofit called the Brehm Foundation to Defeat Breast Cancer. We've recently launched a new online interactive tool to determine whether you need to talk to your doctor about whether you're at high risk called Checkmate. There are other online apps that can help you find what your risks are.

Certainly you can go to a genetic counselor and they will help you figure out whether you're at increased risk. But anybody who has dense breast tissue is at increased risk. But anybody who has dense breast tissue is at increased risk. So women who have dense breast tissue are anywhere between two to six fold, six times higher risk of developing breast cancer. And of course, as you've pointed out before,

that coupled with the fact that having dense breast tissue makes interpreting mammograms much more difficult. So it's kind of like the perfect storm. So my understanding is there's four categories of breast density. We've been over this on a couple of the pods, but that half of them are in the dense category. So it's heterogeneous density and then extremely dense. But in a lot of places, they don't tell you exactly what your density is. They just say you have dense breasts. So in my case, I was even a few days before my mastectomy, I had a mammogram and it was

totally clear. They said we wouldn't have found any cancer here based on this mammography. That's with extremely dense. Is it true that all the folks with dense breasts, including the heterogeneous, would benefit from having the MRIs or is it only if you know you have the extremely dense that you need to have the MRI? So you point out a lot of good things and it's important for the people listening to this podcast to know that you can have breast cancer and have a normal mammogram. It's very important and it's a very important part of finding early breast cancer, but it

really speaks to the fact that even if you had a normal mammogram and you feel something, you really need to advocate for yourself. You really need to go see your doctor if they say, oh, it's nothing, you're too young to advocate for yourself. You really need to go see your doctor. If they say, Oh, it's nothing. You're too young to have breast cancer. If they say it's a cyst without imaging, there is no way any finger can determine a cyst, then go see another doctor. Because at the end of the day, as well-meaning and well-trained as we are,

we're still human, we make mistakes and the consequences can be horrible. But all women with dense breast tissue are at higher risk. The denser you are, the higher your risk. So it's not like, oh, you have dense breasts, you're four times higher risk. The farther you are from non-dense, the higher your risk. It's kind of like a sliding scale. And the extremely dense breasts are the ones

that have the highest risk of developing breast cancer. And they are also the ones that because breast tissue is white on a mammogram and breast cancer is white on a mammogram, that masking effect can really make interpretation of the mammogram more difficult. So anybody with dense breasts has to have additional screening to optimize the opportunity to find early curable breast cancer. And that's what we're all about. I just have a follow-up question just in terms of folks out there who don't know how to advocate for themselves. In this case, we've talked to so many women who they get their yearly mammograms or they skip every other year. And what do they need to

say to their doctors? Let's just say that they want to even get an MRI or an ultrasound and they aren't in the extremely dense or the heterogeneous dense breasts. What do they say so that they can make sure that they A, get the screening and that it can also be covered under insurance? So that's two very complicated questions.

First of all, in September, the FDA is gonna release new guidelines guidelines that every woman is going to have to be told what her breast density is. Yay! Yes, they got that half right. The other half is go talk to your doctor about what else you might need. What they should have said is you need more testing. Right. Which is like what the Brehm Foundation did in DC, which is make sure that we had a law that every person knew their breast density. Every person was told that they required essential additional screenings and that insurance had to cover those additional essential screenings. So good job on that. I couldn't agree more. And you know, the Brehm Foundation is dedicated exclusively to early detection. And we were instrumental in that bill. We work now on multiple other bills around the country.

And we work on the Hill on federal bills like the Find It Early Act. And not only will that ensure that women with dense breasts get the screening they need, that they get the diagnostic tests they need, that it's covered by insurance, but like screening mammography is, as a result of the Affordable Care Act,

that it's with no copay and no deductible. So not only women who have the expendable income to pay the copay for insurance, but that women who would have to decide between feeding their families and paying the copay get to have the additional tests that will find these early, more curable breast cancers. So the find it early act has not been enacted. We work on it.

We do a lot of advocacy on the state and national level. And we've also, you know, find out about programs that might help women break down these barriers. We found out that travel to mammograms was a big hindrance and we wanted to break down barriers and it was a huge barrier. So the Bren Foundation partnered with Lyft, the ride share company, that we offer women who underserved communities free rides to their mammograms, free to them rides to their mammograms so that they can get the life-saving tests they need. But back to the question is how do you advocate for yourself? Maybe the best thing to say is don't be a good girl. You gotta be badass. You can't

accept no for an answer. So if you're going to a practice and someone tells you that you've gotten additional testing because you've had a 3D mammogram, tomosynthesis, that is not additional testing. That is a mammogram. White is white, whether it's 2D or 3D. And I mean, white is white with breast cancer and breast tissue. Additional testing can be ultrasound, can be molecular breast imaging, which is physiologic imaging. A more recent addition to the tool chest is something called contrast enhanced mammography, and the Holy Grail is MRI.

So you need one of these additional tests to find these early curable breast cancers. Oftentimes, the cancers that we find with these additional testing are these early invasive node negative killer, but at that point curable cancers. That's why it's really important to get one of these tests. If you go to a center that says you don't need it, go to another center. You can insist on it.

You just have to really raise your voice. I mean, at our center, we offer every woman with dense breast ultrasound. We also offer artificial intelligence on every mammogram to really use as much of the tools as we can that we have to find early curable breast cancer. That was an interesting question that, you know, in determining whether you're at the right place, that whether they're listening to you, whether they're responding to you, if they're relying on this task force recommendation, you're not in the right place.

But you also said to ask about who is reading the mammography, making sure that that is someone who, what was it, spends at least 70% of their time reading breast mammography. That would be optimal. I had never heard that before. Well, no matter what you do,

if you do more of it, you're better at it, right? So, you know, if you're a musician, they say it takes a hundred thousand hours, 10,000 hours. You know, what if you are a podcast host? I mean, like you guys, you do it frequently. You're so good at it. If you, whatever you do, if you do it a lot, you're better at it. And so in our practice, a hundred percent of the breast imaging is read by breast imagers that do a hundred percent breast imaging. And so the level of expertise is better, no matter what it is. And you deserve the best expertise. And the only way you'll get that is if you raise your voice, you advocate for

yourself and you say, you have every right to say, who's reading my mammogram. for yourself and you say, you have every right to say, who's reading my mammogram? I want someone who reads 70% of their time, at least to spent reading breast imaging. And that is the way to optimize the opportunity to find the earliest breast cancer, to really harness the expertise and experience because it's really important in breast imaging. Okay, so let's say you're going to you have a breast center or you go to your

doctor and you go get your MRI or your mammogram or your ultrasound, how important is it in your mind to go back to the same equipment? To me, I'm like, I think, okay, whoever's reading my scans or the data, if it's being done year after year after year by the same people, is that good or is it bad? Is it good to like take your stuff to go to another doctor and get like a second opinion every once in a while? Because we get into our ruts or we have our doctors. What do you think about that?

I think what's really important is that you have your prior imaging for whoever's interpreting it to interpret it. We know in data studies have shown that one, two, three years of studies can help us see change and change is what we're looking for. And that's what Amanda had. She had that six month change on her MRI. So we look for change. So it doesn't matter that it's in the same place. The expertise of the interpreter is really important, but it does matter that you make

sure that you take on the responsibility of getting your prior images. So we have the opportunity to compare. Great. And in my case, you could ask for those on a disc and actually just bring it with you, which is what I had to do. People should know that those images belong to the patient. They have every right to ask for it and everybody's images can be on a disc. Yeah. That's great. That's great. Yes, they do not belong to the doctor. I've been hearing about fast MRI. Can you speak to that if you're not in a situation

where your doctor just won't order it for you? How reliable are the fast MRIs and what are they costing people if they just elect to want to go do them themselves? They are very accurate. They are excellent. It's out of pocket. It varies somewhere between 250 and 500 or north of that, but that's the price that, you know, the out-of-pocket MRI

insurances are beginning to pay for fast MRIs as well. So we have to make the availability of MRI available to everyone. You do have to remember like everything everything there's a pro and a con, right? Like with mammography, there's very low dose radiation, you get more flying to California if you fly four or five times. But with MRI, you require an injection of a compound called gadolinium. Without it, you can't really see breast cancers. So, you know, we know that that accumulates in the brain. We don't think it does anything, but we are working on new ways of using information about blood flow, which is what this is doing, that doesn't require gadolinium.

And the other consideration is that there are also false positives, right? Normal breast tissue can sometimes look similar, and sometimes it requires a minimally invasive biopsy to determine if you have breast cancer or not. And it's not like everybody should hop on the MR scanner. If you said to me, Rachel, what is the best way to diagnose breast cancer in everybody, it would be the MR scanner for everybody. But it's really not at this point reasonable or something that we should expect that everybody could get an MRI every year. But if you are at increased risk

and your insurance company denies you the MRI, it is really, really important. That is one of the few times that no is not no, right? You just call the insurance company and you say, I am at high risk, and you just take it up the ladder and you ask your doctor to help you with that. I mean, I can't tell you how many,

what we call peer to peers I've had to say. And for me, maybe this is too transparent for a podcast, but there are things you can say to insurance companies that make them an offer that can't refuse, right? I have a question about that. Can I ask you that? First of all, can we do a real quick, just stop and review? Because you two know so much about this that every once in a while I just want to stop and say, okay, what we're talking about is if you are at high risk of breast cancer because you have dense breasts. Dense breasts means it's the quality of the tissue in your breast that makes it almost impossible to see the cancer that you might have through a mammogram.

So in these cases when you have dense breasts, what we're talking about is you must advocate for more tests. Even if you go in every month for a mammogram, it might not see the can, right? You can't go in every month. But even if you did. Yes, I think maybe the way to say it is

that you can have breast cancer and have a normal mammogram. That is a truth. And you live that truth, rightogram. That is a truth. And you live that truth, right? Your family lived that truth. And that's why you have to advocate for these additional tests. There is no test that's perfect. Even MRI sometimes misses a cancer. But it's really, really important to use all the tools that we can to find these early curable breast cancer. And if someone has dense breast tissue, it's important that they get additional testing. That might mean ultrasound. Ultrasound can be a very effective tool to find 25% more cancers. And then if you kick that up a notch, you know,

molecular breast imaging, contrast-enhanced mammography, and ultimately MRI are all technologies that require injections because they look not only at anatomy, like mammography and ultrasound, but physiology, where the blood flow is. And that's what we use to help find additional cancers. Okay. So we figured out we have dense breasts or a higher risk because of family history or the other thing you said, genetic testing, genetic testing. Right. So we go to our doctor, we say I know that I need further testing because I have learned this about dense breasts. And our doctor says, no.

And we call the insurance company. I am always trying to think of vigilante justice. Okay, so I have a friend who does not have a lot of money, who can't do these tests on her own. She knows she should get this testing. Her insurance doesn't cover shit her doctors ignoring her. Is it not? Okay to tell the insurance company that you have a family history that you don't actually have Okay, that's it's not okay. Not okay, but okay that that is not okay because that's an untruth or another word for an untruth

But what you can do is go to another doctor. Right? That is a truth. That is a right that you have. And perhaps ask around to ask your friends come to see us. We will never question that. And we have to be honest. But doctors are humans. And if this one doesn't fit you, then find another doctor. And without a referral, it's really hard to get these tests anyway. But I think what you speak to is that there's so many angles or perspectives about breast cancer, the perspective of the patient, the family, the doctor. And actually that's why Christy Teal, who's the head of breast surgery at GW,

and I wrote No Longer Radical, because there are very few people who have the 360 degree view that we have, right? The daughter of a woman who had breast cancer, as Christy is, I had breast cancer, I have three daughters, some of whom are more open. Andrea is very open about the fact that she wanted to change the narrative of our family

and the other girls as well. And they've changed that narrative by difficult surgery, right, Amanda, difficult surgery, but a whole lot better than cancer and chemotherapy. And the whole premise of No Longer Radical is that knowledge is power and you have to advocate for yourself, but you have to have this knowledge to know what to advocate for. And that maybe if you're very dense, you feel your breasts super carefully, wink, wink, and maybe you feel something a little. Okay. That's the truth, right? I am not advocating anything but truth. We got everybody's got stuff that they can feel in there.

There's stuff going on in there. Okay, great. And that's what I'm saying. I so enjoyed listening to the podcast that you had when you were first diagnosed, talking about how you're gonna deal with your family and I, or not deal, and I share that. You know, sometimes you just have to build a wall

to get through things that are unfathomable and that wall kind of breaks down with time. And I think my family would tell you sometimes that wall never breaks down completely. But my husband, in the times that we were feverishly writing the book, he sheepishly came up to me and said, do you have a chapter for the life partner of people with breast cancer? And I sort of looked up and said, wow, now we do, because that's such an important part. And you really addressed that so early on in your journey. But we really talk about how to advocate for yourself, what you need to know. I'd like to say that it's a compassionate, comprehensive book that has both the emotional space

and the informational space to advocate for yourself for so many things. We even put questions to ask your doctor at the end of the chapter. And that might be helpful in trying to negotiate how to get the optimal testing that you need. And I think things are changing. So in Pennsylvania, it's the only state right now,

anybody who has the kind of dense breast that you had extremely dense breast, or who have heterogeneously dense and one other risk factor has insurance requirement for coverage of MRIs. So we're taking small baby steps and we've got to make those giant steps to make it available for every person to have the diagnosis of the earliest most curable breast cancer. But I think the vast MRIs is the entree into making MRI available for everybody who needs it. And we just have to keep pushing forward.

But don't accept no. I can't tell you how many women have come up to us after our informational sessions through the Brehm Foundation that advocated for themselves and a small early high grade triple negative breast cancer was found on an MRI that they had to fight for. So, you know, raise your voices, be badass, don't accept no. And if your doctor is not on board, then get another doctor that's better than making up things that might not be so.

Okay, we're gonna wrap up here for today, but we're gonna come back on Thursday. And when we do, we're gonna have more important information from Dr. Brehm on what each of us should do to make sure we have the information we need about our own bodies and our own health. Plus, we're sharing some beautiful messages from you, Pod Squad, with your wisdom and experience and guidance

from walking this path. Thank you for trusting us with your stories and for sharing them with the Pod Squad so we can all learn from your experiences. See you next time. If this podcast means something to you, See you next time. If this podcast means something to you, it would mean so much to us. If you'd be willing to take 30 seconds to do these three things. First, can you please follow or subscribe to We Can Do Hard Things?

Following the pod helps you because you'll never miss an episode and it helps us because you'll never miss an episode and it helps us because you'll never miss an episode. To do this just go to the We Can Do Hard Things show page on Apple podcasts, Spotify, Odyssey or wherever you listen to podcasts and then just tap the plus sign in the upper right hand corner or click on follow. This is the most important thing for the pod. While you're there if you'd be willing to give us a five-star rating and review and share an episode you loved with a friend, we would be so grateful. We appreciate you very much. We Can Do Hard Things is created and hosted by Glennon Doyle, Abby Wambach and Amanda Doyle in partnership with Odyssey. Our executive producer is Jenna Wise Berman

and the show is produced by Lauren Legrasso, Alison Schott, Dina Kleiner, and Bill Schultz. I give you Tish Melton and Brandy Carlisle. I walked through fire. I came out the other side. I chased desire, I made sure I got what's mine And I continue to believe that I'm the one for me And because I'm mine I walk the line Cause we're adventurers and heartbreaks on map

A final destination we lack We've stopped asking directions To places they've never been And to be loved we need to be known We'll finally find our way back home and through the joy and pain that our lives bring we can do our thing I hit rock bottom, it felt like a brand new start I'm not the problem, sometimes things fall hard And I continue to believe The best people are free And it took some time But I'm finally fine We're adventurers and heartbreaks on that

A final destination with that We've stopped asking directions To places they've never been And to be loved we need to be known We'll finally find our way back home And through the joy and pain That our lives bring We can do hard things

We're adventurers and heartbreaks on back We might get lost but we're okay now We've stopped asking directions In some places they've never been and to be loved we need to be known we'll finally find our way back home and through the joy and pain that our lives bring we can do hard things Yeah, we can do hard things Yeah, we can do hard things