# Elisa Port: Discuss THE BREAST ADVICE Book

An episode of [Ground Truths](https://invisiblenetwork.ai/podcast/1728526108), 26 Jun 2026, 1 h 04 min.

Audio: https://api.substack.com/feed/podcast/196570345/d3da9011d5314ae85be22fb62c75d2d2.mp3

“I may be the expert in cancer, but you are the expert in you.”—Elisa Port, MD Ground Truths is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. Dr. Elisa Port is Professor of Surgery, Icahn School of Medicine at Mount Sinai; Chief of Breast Surgery for the Mount Sinai Health System; Director of the Dubin Breast Center; and Director of the Center of Excellence for Breast Cancer at the Mount Sinai Tisch Cancer Center, a NCI-Designated Comprehensive Cancer Center. She is remarkably well qualified to provide guidance for prevention and treatment of breast cancer, and runs a model program at Mount Sinai in New York (←we’ll get into why I say that). She has just published a terrific book that centers around the concept of informed optimism. Many of her patient stories are integrated. We tried to cover the waterfront during our conversation including: —4 Ws for reduction of risk: weight, walking, wine, and working out (especially in Nature, “green exercise”) —Only 10-12% of women will ever develop breast cancer during their lives —Role of adipocytes (fat cells), aka estrogen and inflammation factories —Misinformation (underlying the need for this book) —Pervasive myths of magic supplements, with safety issues of unregulated intravenous drips and others when analyzed turned out to be crushed up, dried house plants —Total body MRI: mixed results from her patients —Breast cancer on the rise in young women. Dr. Port relates about recent patients diagnosed in their 20s. Some without BRCA or other pathogenic mutation. Why? —Mammograms in non-dense breasts pick up 80-90% of breast cancer. It’s the 40-50% women with dense breasts, which the scan is trying to find a polar bear in a snowstorm, is a problem. The problem with false-positives. —Use of AI with mammography for increased initial detection, prevention, detect high-risk in women with a “normal” mammogram, and risk of heart disease (see my recent Ground Truths and piece in The Lancet on this important topic) —Mount Sinai provides Transpara AI (the one validated by the big Sweden trial of >100,000 women) to all women getting mammograms FOR FREE. That is the best validated AI tool in medicine today! —How a mammogram saved a patient’s life, not about breast cancer! —Hormone replacement and birth control pills. How to assess benefit and risk in women young and older? Differences in the hormone risks. —Tamoxifen for primary prevention in high-risk people. Reduction of breast cancer in 50% or more in these women. In some subgroups reduction as high as 80%! —GLP-1 drugs may reduce breast cancer risk and this may not just be related to weight loss —Lack of utilization of Genetic testing (it could be your father). I disagreed with respect to use of polygenic risk scores, as I wrote about in SUPER AGERS —“I just wanted to scream out on top of the mountain about genetic testing, family history, and early screening.” Tennis legend Chris Evert —The lack of our ability to assess the immune system in the clinic and how that could change the face of prevention and very early detection of breast cancer An infographic summary I made on Dr. Port’s book with the help of NotebookLM **************************************** Thank you YOUR DOCTOR KLOVER, Diane Romero, Bob Fleischman, Danielle, MagnaAnimus, and 450+ others for tuning into my live video with Elisa Port! Join me for my next live video in the app. A big thanks to all the Ground Truths subscribers from every US state and 212 countries. Your subscription to these free essays and podcasts makes my work in putting them together worthwhile. If you’re not a subscriber, please join! If you found this interesting PLEASE share it! Paid subscriptions are voluntary and all proceeds from them go to support Scripps Research. They do allow for posting comments and questions, which I do my best to respond to. Please don’t hesitate to post comments and give me…

## Transcript

[0:01] SPEAKER_01: Start Our Conversation
[0:17] SPEAKER_01: Well,
[0:17] SPEAKER_01: today,
[0:18] SPEAKER_02: I'm really privileged because I've got with me Dr.
[0:22] SPEAKER_02: Elisa Port,
[0:23] SPEAKER_02: who heads up breast surgery at Mount Sinai Hospital.
[0:26] SPEAKER_02: And she has a great book,
[0:29] SPEAKER_02: The Best Advice,
[0:30] SPEAKER_02: or The Breast Advice,
[0:33] SPEAKER_02: about its prevention,
[0:35] SPEAKER_02: its screening,
[0:36] SPEAKER_02: and treatment.
[0:37] SPEAKER_02: And so we're going to get into that.
[0:39] SPEAKER_02: And so it is really a delight, Elisa, to welcome you to Ground Truths.
[0:45] SPEAKER_00: Thank you so much for having me.
[0:46] SPEAKER_00: It's really an honor and a privilege.
[0:50] SPEAKER_02: Well, this book is going to be out next week.
[0:55] Really a stunner because it's got so much great information
[0:59] about breast cancer.
[1:01] And I thought we'd start with,
[1:03] you know,
[1:03] it's always good for remembering things when you have
[1:07] as you had the three W's or the four W's about we know there's
[1:12] a few hundred
[1:12] thousand cases of breast cancer a year in the United States and
[1:17] the survival rate
[1:18] SPEAKER_02: has improved so much now.
[1:20] SPEAKER_02: Yes.
[1:21] SPEAKER_02: 90%.
[1:22] SPEAKER_02: But there are the big ones that you the lifestyle things you can do
[1:28] SPEAKER_02: to reduce the risk,
[1:30] even though only 12% of women throughout their whole lifespan
[1:34] will have breast
[1:34] SPEAKER_02: cancer,
[1:35] SPEAKER_02: but those 12%,
[1:36] SPEAKER_02: we want to make sure that they don't show up.
[1:38] SPEAKER_02: So tell us about the three W's or the four W's.
[1:42] SPEAKER_00: Yeah, I mean, thank you so much.
[1:44] SPEAKER_00: You know,
[1:44] SPEAKER_00: I think one of the things that is really interesting about this book is,
[1:49] SPEAKER_00: of course,
[1:50] SPEAKER_00: it's a guide for navigating a diagnosis of breast cancer,
[1:52] SPEAKER_00: but the whole first half of the book,
[1:54] SPEAKER_00: Eric,
[1:54] SPEAKER_00: as you say,
[1:54] SPEAKER_00: is about breast health,
[1:56] SPEAKER_00: right?
[1:56] SPEAKER_00: And
[1:57] And the,
[1:59] you know,
[1:59] the interesting thing is I always say it's just not that
[2:03] tricky.
[2:04] Breast health is,
[2:05] what's good for your breasts is good for the rest of you.
[2:07] SPEAKER_00: So the main factors that we focus on, the four W's are weight, weight,
[2:15] SPEAKER_00: Walking Wine You know, those are the three main ones.
[2:22] SPEAKER_00: And I add the fourth one, which is working out, right?
[2:26] SPEAKER_00: And let's talk about the first three first.
[2:28] So the main lifestyle factors that could put you at the lowest
[2:35] possible risk for
[2:36] SPEAKER_00: getting breast cancer based on lifestyle load,
[2:39] SPEAKER_00: number one is weight,
[2:41] SPEAKER_00: and number two is alcohol intake.
[2:44] SPEAKER_00: It turns out there had been a lot of mixed data about alcohol.
[2:48] SPEAKER_00: It turns out where people said,
[2:50] SPEAKER_00: if you drink in moderation,
[2:51] SPEAKER_00: it probably doesn't affect your risk that much.
[2:54] It turns out that the safest amount of alcohol as it relates to
[3:00] breast cancer risk is zero.
[3:02] SPEAKER_00: Okay.
[3:03] That doesn't mean that you're bumping your risk up so
[3:07] dramatically if you drink in moderation.
[3:10] SPEAKER_00: You know, um,
[3:11] if someone has I always say you know we have to live our lives
[3:14] and so to have a
[3:15] SPEAKER_00: glass of champagne at you know your son's wedding or
[3:19] SPEAKER_00: You know, this person's, you know, celebration.
[3:22] SPEAKER_00: It's like be a human, be a person.
[3:25] SPEAKER_00: And so to have,
[3:26] SPEAKER_00: you know,
[3:26] SPEAKER_00: a couple of drinks a week,
[3:28] SPEAKER_00: especially if you enjoy that,
[3:30] SPEAKER_00: really shouldn't bump up your risk too much.
[3:34] And I say that it's really,
[3:36] it's just a question of being,
[3:37] I think,
[3:38] aware.
[3:40] SPEAKER_00: What a lot of people say is, yeah, I don't drink that much.
[3:42] SPEAKER_00: I just have a glass of wine with dinner every night.
[3:46] But when I see a patient who's diagnosed with breast cancer and
[3:49] we start digging
[3:50] SPEAKER_00: deeper,
[3:50] SPEAKER_00: it turns out that's seven drinks a week.
[3:54] And then when you take that person and you find out they also
[3:57] go out on a Saturday
[3:58] SPEAKER_00: night and then they have a cocktail and then they have a glass of wine,
[4:00] SPEAKER_00: now you're getting into seven to ten.
[4:02] So what I tell people is just be mindful and self-aware and
[4:08] honest about what your
[4:09] SPEAKER_00: alcohol consumption is.
[4:11] SPEAKER_00: And if there is room for improvement, there's room for improvement.
[4:16] SPEAKER_00: So that's that.
[4:17] SPEAKER_00: As it relates to weight, weight is another big one.
[4:19] SPEAKER_00: You know,
[4:20] it turns out that everyone thinks fat stores in our bodies are
[4:23] just like these
[4:24] SPEAKER_00: passive blobs of tissue that kind of just hang off of us.
[4:27] SPEAKER_00: They're not.
[4:28] SPEAKER_00: They're extremely metabolically active.
[4:32] And one of the things most people don't realize is that in
[4:35] postmenopausal women,
[4:36] SPEAKER_00: right,
[4:37] SPEAKER_00: we all think that when you're postmenopausal,
[4:39] SPEAKER_00: your estrogen,
[4:41] SPEAKER_00: your ovaries have kind of shut down
[4:43] Production Right Factories Closed No More Estrogen Production
[4:47] But We're Still Women
[4:49] Right Our Voices Don't Deepen We Don't Grow Beards So Where's
[4:52] That Estrogen Coming
[4:53] SPEAKER_00: From
[4:54] SPEAKER_00: It comes from other sources.
[4:55] SPEAKER_00: It can come from the adrenal glands.
[4:57] SPEAKER_00: It can come from the skin.
[4:58] SPEAKER_00: And it can also come from fat stores.
[5:00] SPEAKER_00: Fat stores are one of the biggest sources of estrogen production.
[5:05] So it doesn't come as some surprise that if you have an
[5:11] extensive amount of fat
[5:12] SPEAKER_00: stores and you are producing more estrogen that is then released in the
[5:16] SPEAKER_00: bloodstream,
[5:16] SPEAKER_00: that could increase the risk of breast cancer recurrence.
[5:19] SPEAKER_00: Yeah.
[5:19] SPEAKER_02: So the adipocytes, they're a double hit because they're also...
[5:24] SPEAKER_02: producing inflammatory mediators and the estrogen.
[5:28] SPEAKER_02: So it's good not to have many of those around or too many, right?
[5:33] SPEAKER_00: I couldn't agree more.
[5:34] SPEAKER_00: And so those are the things that a person could do,
[5:36] SPEAKER_00: you know,
[5:37] SPEAKER_00: the wine and the walking and the weight and then working out,
[5:41] SPEAKER_00: you know,
[5:41] SPEAKER_00: exercise is super important.
[5:43] SPEAKER_00: And I tell people go hard,
[5:45] SPEAKER_00: you know,
[5:46] SPEAKER_00: that's really,
[5:46] SPEAKER_00: really important to challenge your body in those ways.
[5:49] SPEAKER_02: Well,
[5:49] SPEAKER_02: what's good about the working out and the walking,
[5:52] SPEAKER_02: you emphasize that most people don't,
[5:54] SPEAKER_02: is being outdoors.
[5:58] SPEAKER_02: I wrote Super Agers,
[6:00] SPEAKER_02: I reviewed all the literature about being out in nature,
[6:02] SPEAKER_02: and there's a bonus effect of that.
[6:04] SPEAKER_02: So it's not just you're exercising in a basement,
[6:07] SPEAKER_02: a garage,
[6:08] SPEAKER_02: or whatever,
[6:08] SPEAKER_02: but if you're outdoors,
[6:10] SPEAKER_02: it's even more beneficial.
[6:12] SPEAKER_00: We call it green exercise, which I write a whole section on.
[6:18] SPEAKER_02: Yeah, it's perfect.
[6:19] And I wanted to start with that because in a way,
[6:24] it's a prescription for all people,
[6:27] all women.
[6:28] SPEAKER_02: But also, we're going to get into genetic risk.
[6:31] SPEAKER_02: And maybe if you are high risk,
[6:33] SPEAKER_02: it's even more important than if you're deemed at very low risk,
[6:36] SPEAKER_02: which we can get to.
[6:38] SPEAKER_02: So that's a good starting point.
[6:40] SPEAKER_02: We're going to come back to that.
[6:42] SPEAKER_02: Now,
[6:43] SPEAKER_02: in the book,
[6:43] SPEAKER_02: what's great is you deal with these magic supplements,
[6:49] the fact that the New York Attorney General did a big study and
[6:53] found out that
[6:54] SPEAKER_02: these weren't even what they said they were.
[6:56] SPEAKER_02: They could be dried, crushed houseplants or anything.
[7:03] SPEAKER_02: And also the people that get breast cancer,
[7:07] SPEAKER_02: they're thinking it's sugar,
[7:08] SPEAKER_02: it's stress,
[7:09] SPEAKER_02: it's plastics.
[7:11] Can you set this straight about the whole supplement and the
[7:16] other liabilities that
[7:18] SPEAKER_02: are coming into play here?
[7:21] SPEAKER_00: Yeah, sure.
[7:22] SPEAKER_00: I mean,
[7:22] SPEAKER_00: what I say about supplements,
[7:24] what people just need to really be aware of is that they're not
[7:27] regulated.
[7:29] SPEAKER_00: And what that means is that not only do you not know what you get,
[7:36] SPEAKER_00: you don't even know what you're getting kind of batch to batch.
[7:40] So make believe you do decide for whatever reason that ginkgo
[7:44] biloba is really
[7:45] SPEAKER_00: important to you and important to whatever it is,
[7:48] SPEAKER_00: your memory or your joints or whatever.
[7:52] um when you go to because they're unregulated there doesn't
[7:57] even have to be
[7:58] consistency in the amount and the dosing you get why because if
[8:03] there's never any
[8:05] SPEAKER_00: established safe effective dose to begin with what you know what
[8:13] SPEAKER_00: Make someone give you that amount in the production.
[8:17] SPEAKER_00: And that's what happens with the lack of regulation.
[8:21] SPEAKER_00: And so what I say,
[8:22] the irony to me is that I find that people who take a lot of
[8:25] supplements are people
[8:26] SPEAKER_00: who say,
[8:26] SPEAKER_00: I'm very skeptical about side effects from medication.
[8:30] SPEAKER_00: And I agree,
[8:31] SPEAKER_00: there are side effects from medication,
[8:33] SPEAKER_00: but at least from medication,
[8:35] SPEAKER_00: they're regulated.
[8:36] There's usually billions of dollars of science that have gone
[8:40] in to establish
[8:42] What the safe things are and what the unsafe things are and the
[8:46] proper dosing.
[8:48] So the irony to me is like if you're a person at all that is at
[8:52] all skeptical or
[8:54] SPEAKER_00: paranoid about what you put in your body,
[8:57] SPEAKER_00: don't do that because it's like kind of a black box.
[9:00] SPEAKER_00: And I do think,
[9:02] SPEAKER_00: you know,
[9:03] SPEAKER_00: there have been studies that show,
[9:04] SPEAKER_00: for example,
[9:05] that 60 to 80 percent of people who take supplements don't
[9:09] divulge them to their
[9:10] SPEAKER_00: doctors.
[9:12] SPEAKER_00: And so you're put on medication sometimes,
[9:14] SPEAKER_00: whether it be for cholesterol or for heart or whatever.
[9:18] And some of these things that are biologically active can have
[9:21] interference effects.
[9:24] You know,
[9:24] there's huge amounts of emergency room visits every year
[9:27] related to supplements.
[9:29] Sometimes it's the muscle builder stuff that has caffeine in it
[9:32] and people get
[9:33] SPEAKER_00: racing heart rates and they think they're having a heart attack.
[9:37] Other times it's liver toxicity because some of the stuff is
[9:40] broken down by the liver.
[9:42] SPEAKER_00: And so I just think that it's really...
[9:47] And I also think to me the sad part is a lot of times people
[9:50] are spending money on
[9:51] SPEAKER_00: this who can ill afford to do that.
[9:54] SPEAKER_00: You know, it's a little bit predatory.
[9:57] So I just say I would ask people or my plea would be be as
[10:02] skeptical about the
[10:06] SPEAKER_00: supplements as you are about regular medications.
[10:09] SPEAKER_00: And if someone tells you
[10:11] SPEAKER_00: You know,
[10:12] you can't put something in your mouth and have it have only
[10:15] good effects and no bad
[10:16] SPEAKER_00: effects.
[10:16] SPEAKER_00: There's just no such thing as that.
[10:19] SPEAKER_00: So if you are being told or suggested to take a supplement,
[10:22] SPEAKER_00: I think the first question you ask are,
[10:23] SPEAKER_00: what are the side effects?
[10:25] And if someone kind of stares at you blankly or says there are
[10:29] none,
[10:29] walk away.
[10:30] SPEAKER_00: Because it's just not possible.
[10:32] SPEAKER_00: You know, you can have a gastric ulcer from an aspirin.
[10:37] SPEAKER_00: You can get liver toxicity from a Tylenol.
[10:39] SPEAKER_00: These are basic things.
[10:40] SPEAKER_00: And we accept that in medications.
[10:42] But if it's having any kind of positive biological effect on
[10:45] some level somewhere,
[10:47] SPEAKER_00: there's got to be a side effect.
[10:49] SPEAKER_00: And it's important to know what those are.
[10:51] SPEAKER_02: Yeah,
[10:51] SPEAKER_02: and I would just add on,
[10:53] SPEAKER_02: I couldn't agree with you more on what you just reviewed,
[10:55] SPEAKER_02: but the unregulated peptides that are very popular,
[11:00] SPEAKER_02: particularly out here in California,
[11:02] SPEAKER_02: but now spreading in the country.
[11:04] SPEAKER_02: Some of these are growth hormone-related peptides.
[11:08] SPEAKER_02: And we don't know,
[11:09] SPEAKER_02: I mean,
[11:09] it isn't like when you have cells proliferate that it won't be
[11:14] cancer cells
[11:15] SPEAKER_02: eventually.
[11:16] SPEAKER_02: So much unknown here and the people that are doing this stuff,
[11:19] SPEAKER_02: it's just,
[11:20] SPEAKER_02: you know,
[11:21] SPEAKER_02: it's just very dangerous.
[11:23] SPEAKER_02: As you say, no costly and the long-term issues as well.
[11:28] Now,
[11:29] related to that,
[11:30] there's also a big craze of people getting total body MRIs.
[11:36] SPEAKER_00: Love that topic.
[11:38] SPEAKER_02: Yeah.
[11:38] SPEAKER_02: I mean, another one here you get into, but this is a problem, right?
[11:44] SPEAKER_00: Well, I would say it's mixed.
[11:48] SPEAKER_00: You know, I write a chapter in the book.
[11:50] SPEAKER_00: I try to be super balanced.
[11:52] SPEAKER_00: In the book,
[11:53] SPEAKER_00: there is a chapter about full body screening,
[11:55] SPEAKER_00: and I have one person who says,
[11:58] SPEAKER_00: the total body scan saved my life.
[12:00] SPEAKER_00: And I have another person who says the total body scan ruined my life.
[12:05] SPEAKER_00: How is that?
[12:05] SPEAKER_00: Well,
[12:06] SPEAKER_00: every once in a while,
[12:08] SPEAKER_00: you know,
[12:08] SPEAKER_00: if you do one of these total body scans,
[12:11] SPEAKER_00: they are going to find things.
[12:12] SPEAKER_00: There's about a 10% chance that they'll find something.
[12:15] SPEAKER_00: Of those, it's a less than a 1% chance that it's cancer.
[12:19] SPEAKER_00: So yes,
[12:20] SPEAKER_00: every once in a while,
[12:21] SPEAKER_00: you're going to find a cancer,
[12:24] whether it's a lung cancer or pancreatic cancer or one of these
[12:26] cancers that's more
[12:27] SPEAKER_00: difficult to screen for.
[12:30] SPEAKER_00: You know,
[12:31] SPEAKER_00: and I think there's no question that whether it's one in a thousand,
[12:36] SPEAKER_00: one,
[12:36] SPEAKER_00: you know,
[12:37] SPEAKER_00: 0.1% or one in 10,000,
[12:39] SPEAKER_00: at some point someone's going to attribute a scan,
[12:43] SPEAKER_00: you know,
[12:43] SPEAKER_00: an early cancer detection that they wouldn't have done.
[12:46] SPEAKER_00: Eric Topol erictopol
[13:14] SPEAKER_00: You know,
[13:15] I have a patient who really believes that getting the scan and
[13:18] spending her
[13:19] SPEAKER_00: hard-earned money,
[13:19] SPEAKER_00: because they do cost money,
[13:21] SPEAKER_00: they're not validated or covered by insurance,
[13:26] SPEAKER_00: saved her life.
[13:27] SPEAKER_00: And I also have a patient who got the scan,
[13:30] SPEAKER_00: and she got it,
[13:30] SPEAKER_00: I think,
[13:31] SPEAKER_00: as a present from her boss,
[13:32] SPEAKER_00: like a Christmas present.
[13:34] SPEAKER_01: Wow.
[13:36] SPEAKER_00: did the scan and called me panic-stricken.
[13:38] SPEAKER_00: And there was something, a small thing in the tail of the pancreas.
[13:41] SPEAKER_00: They didn't know if it was a cyst or this or that.
[13:44] And it was in a place that was too dangerous to biopsy that led
[13:47] to about five other
[13:49] SPEAKER_00: different tests that couldn't tell someone this way or that way.
[13:52] SPEAKER_00: And she was stuck in that,
[13:54] SPEAKER_00: what I call,
[13:54] SPEAKER_00: you know,
[13:55] SPEAKER_00: no man's land,
[13:56] SPEAKER_00: where in the end,
[13:57] SPEAKER_00: everyone said after every single test,
[13:59] SPEAKER_00: a CAT scan,
[14:00] SPEAKER_00: a PET scan,
[14:01] SPEAKER_00: this and that,
[14:02] Everyone said,
[14:02] look,
[14:03] either you need an operation or you just have to wait three
[14:06] months.
[14:07] And the operation is this risks and that risks and bleeding and
[14:10] infection.
[14:10] SPEAKER_00: It's like a major abdominal operation.
[14:12] And she decided to wait three months,
[14:15] but she said it was the worst three months of her life.
[14:18] She basically lost those three months waiting for the scan to
[14:21] be repeated to show
[14:22] SPEAKER_00: that there was no change.
[14:24] and you know her advice was remember the breast advice is not
[14:27] the bulk is not just
[14:28] my advice it's patient advice her advice was proceed with
[14:31] caution you know yeah
[14:33] well that's one of the great parts of the book is that it's
[14:36] through patients
[14:37] experiences yeah you know you're not just talking about it from
[14:40] your experience but
[14:41] you're bringing patients well that's what I say it's a marriage
[14:46] it's too often all
[14:47] SPEAKER_00: you're getting is a doctor's advice in this silo Erica
[14:51] SPEAKER_00: or patient experience in this silo.
[14:54] SPEAKER_00: And it's time we start marrying those two.
[14:56] SPEAKER_00: That is how a lot of people,
[14:58] SPEAKER_00: especially in breast cancer,
[15:00] SPEAKER_00: as you mentioned,
[15:01] SPEAKER_00: it is the most common cancer that women get.
[15:04] SPEAKER_00: So everyone is either had it personally,
[15:07] SPEAKER_00: knows someone,
[15:08] SPEAKER_00: knows someone who knows someone,
[15:10] SPEAKER_00: and there's a lot of people affected.
[15:13] SPEAKER_00: And so
[15:14] SPEAKER_00: The advice from other women,
[15:16] SPEAKER_00: that is in the field of breast cancer,
[15:17] SPEAKER_00: how a lot of women get information from other patients.
[15:21] And those things are super important,
[15:24] those stories and the experiential aspect of it.
[15:28] SPEAKER_00: But no cases are also exactly the same.
[15:31] SPEAKER_00: And so the advice you get medically from another person
[15:35] SPEAKER_00: may not be the same.
[15:36] SPEAKER_00: You know,
[15:36] SPEAKER_00: women come into my office all the time and say,
[15:39] SPEAKER_00: hi,
[15:39] I'm here today because I was just diagnosed and you treated my
[15:42] friend Jane who had
[15:43] SPEAKER_00: the exact same thing.
[15:45] SPEAKER_00: And I'm thinking to myself, I'm like, yeah, I remember that case.
[15:48] SPEAKER_00: This is not the same from my medical perspective.
[15:51] SPEAKER_00: And so what I say is we need to combine these two,
[15:55] the patient experiential aspects and the doctor expertise and
[15:59] marry those two.
[16:01] SPEAKER_02: Yeah, no, that's great.
[16:02] SPEAKER_02: Now, when it gets to the genetics, I have a lot of frustration here.
[16:10] SPEAKER_02: As you point out in the book,
[16:11] SPEAKER_02: you have a whole chapter about,
[16:13] SPEAKER_02: you know,
[16:13] SPEAKER_02: it could be your father because a lot of men are carrying BRCA genes,
[16:19] SPEAKER_02: particularly BRCA2.
[16:23] It might not have shown up as breast cancer,
[16:25] but it showed up for them and could be
[16:27] SPEAKER_02: It could be pancreatic cancer.
[16:30] SPEAKER_02: So we don't screen.
[16:31] SPEAKER_02: We don't get just the pathogenic genes like BRCA's and others,
[16:35] SPEAKER_02: but we also don't get polygenic risk scores.
[16:38] SPEAKER_02: And so some medical centers around the country,
[16:41] SPEAKER_02: like Mass General Brigham,
[16:43] SPEAKER_02: are offering their patients,
[16:45] SPEAKER_02: and for the common cancers like breast and others,
[16:49] SPEAKER_02: also for heart disease,
[16:51] SPEAKER_02: they're offering,
[16:52] SPEAKER_02: you know,
[16:53] SPEAKER_02: this is a SNP chip.
[16:54] SPEAKER_02: This is a cheap test.
[16:56] SPEAKER_02: You know,
[16:56] SPEAKER_02: it's looking at a million variants of the genome,
[16:59] SPEAKER_02: so it's not a sequence,
[17:00] SPEAKER_02: which also could be relatively inexpensive.
[17:03] SPEAKER_02: And we're not using these so that,
[17:05] SPEAKER_02: for example,
[17:06] SPEAKER_02: if you go back to the alcohol,
[17:08] or as we're going to talk about hormone replacement therapy or
[17:12] birth control pills,
[17:14] SPEAKER_02: the people are just being treated all the same,
[17:17] SPEAKER_02: and they're not getting their genetics
[17:20] SPEAKER_02: characterization,
[17:22] SPEAKER_02: either by a SNP chip,
[17:23] SPEAKER_02: you know,
[17:24] SPEAKER_02: a simple polygenic risk score for breast cancer,
[17:27] SPEAKER_02: or the idea of getting sequencing,
[17:30] SPEAKER_02: especially when there's cancer running in the family,
[17:33] especially since it may not be the mother is a classic case or
[17:38] the aunt or
[17:39] SPEAKER_02: whatever.
[17:39] SPEAKER_02: So can you comment about the underuse of...
[17:43] SPEAKER_00: Yeah,
[17:44] SPEAKER_00: I think,
[17:45] SPEAKER_00: let me first say the underuse of standardized genetic testing,
[17:49] SPEAKER_00: which is really true.
[17:50] SPEAKER_00: Look,
[17:52] SPEAKER_00: there are a number of genes where if you have a mutation,
[17:57] SPEAKER_00: there is a quantifiable increased risk of getting breast cancer.
[18:02] You bring up the BRCA genes are the most well-known because
[18:05] we've known about them
[18:07] SPEAKER_00: since 1994,
[18:08] SPEAKER_00: 1995.
[18:10] SPEAKER_00: And those genes are the ones that if you have a mutation,
[18:14] SPEAKER_00: which you can inherit from either a mother or a father,
[18:18] SPEAKER_00: you have the highest quantifiable risk of getting breast cancer.
[18:22] SPEAKER_00: Your risk of getting breast cancer is 60 to 80%.
[18:25] SPEAKER_00: There's also,
[18:25] SPEAKER_00: as you pointed out,
[18:26] SPEAKER_00: Eric,
[18:27] other cancers that can affect both women and men that are
[18:31] associated with those
[18:32] SPEAKER_00: genes.
[18:33] Ovarian in women,
[18:34] prostate in men,
[18:36] pancreatic in both,
[18:37] melanoma,
[18:39] male breast cancer,
[18:41] etc.
[18:41] SPEAKER_00: So
[18:42] SPEAKER_00: Genetic testing just for the—and again,
[18:46] SPEAKER_00: beyond BRCA1 and 2,
[18:47] SPEAKER_00: there's another 6 to 10 genes,
[18:50] SPEAKER_00: PALB2,
[18:51] SPEAKER_00: CHECK2,
[18:52] SPEAKER_00: ATM,
[18:53] that we standardly test for that also can increase the risk of
[18:58] breast cancer.
[18:59] SPEAKER_00: I call them intermediate because their risk is usually 20 to 40%,
[19:04] SPEAKER_00: not the same as the BRCA genes.
[19:05] SPEAKER_00: But they're still—
[19:07] SPEAKER_00: Actionable and we screen those people better.
[19:11] Sometimes we do preventive surgery in those people and so it's
[19:14] important to know.
[19:16] SPEAKER_00: So, you know, for sure genetic testing needs to be wider spread.
[19:24] as it relates to the general population to define those at the
[19:28] highest risk so we
[19:30] SPEAKER_00: can do better as it relates to both high-risk screening or prevention.
[19:37] SPEAKER_00: You know,
[19:37] I think to some degree there's a reluctance on the public's
[19:40] part to do some genetic
[19:42] testing because there is a misconception that if you test
[19:47] positive for like the
[19:48] SPEAKER_00: BRCA gene,
[19:49] SPEAKER_00: you're going to be kind of bullied into doing
[19:54] um very dramatic extensive surgery to prevent cancer some women
[19:59] do choose to do
[20:01] bilateral mastectomies if they're BRCA positive because the
[20:04] risk is so high but
[20:05] nobody really pushes or should push someone into doing anything
[20:10] because we do have
[20:11] SPEAKER_00: really good screening for breast cancer um
[20:15] SPEAKER_00: The polygenic stuff,
[20:17] SPEAKER_00: I will tell you,
[20:18] is really complicated and kind of not ready for prime time in
[20:22] breast cancer yet.
[20:23] SPEAKER_00: You know, for sure we need to do better with our risk models.
[20:27] SPEAKER_00: You know,
[20:28] SPEAKER_00: we have a breast cancer risk assessment tool online,
[20:31] SPEAKER_00: the Tyra Cusick,
[20:32] SPEAKER_00: where you plug in,
[20:33] SPEAKER_00: like,
[20:34] when you got your period and how dense your breasts are and how
[20:38] many family
[20:39] Relatives you have who had breast cancer and if you've had
[20:42] biopsies and what have
[20:43] SPEAKER_00: they shown,
[20:43] SPEAKER_00: etc.
[20:44] SPEAKER_00: And that can put,
[20:47] it spits out a score and a risk for breast cancer that can then
[20:51] also help people to
[20:52] SPEAKER_00: find the risk.
[20:53] SPEAKER_00: But the polygenic stuff,
[20:55] SPEAKER_00: like to give you an example,
[20:57] sometimes we do that with BRCA gene carriers to see if it dials
[21:01] up or dials
[21:02] SPEAKER_00: Down Risk from that 60 to 80%.
[21:05] SPEAKER_00: The problem is,
[21:05] is none of that data has shown yet that you can get the risk to
[21:10] lower than,
[21:10] SPEAKER_00: say,
[21:11] SPEAKER_00: like a 40 or 50%.
[21:13] SPEAKER_00: And so those women still consider themselves at a high risk.
[21:17] SPEAKER_00: We're just too...
[21:17] SPEAKER_00: Eric Topol erictopol
[21:32] And we're just unfortunately not there yet,
[21:33] but I do think that day is coming.
[21:58] Yeah,
[21:58] no,
[21:58] some have already adopted it in some parts of the country and
[22:03] around the world.
[22:03] SPEAKER_02: Now,
[22:03] SPEAKER_02: Sally James pointed out about a guy transmitting,
[22:08] SPEAKER_02: or a father,
[22:09] SPEAKER_02: or she's by the brothers,
[22:10] SPEAKER_02: and by the,
[22:11] SPEAKER_02: you know,
[22:12] SPEAKER_02: a BRCA gene or other pathogenic mutations.
[22:16] SPEAKER_02: So important for people to acknowledge,
[22:18] SPEAKER_02: and like I said,
[22:19] SPEAKER_02: you have a dedicated chapter in the book.
[22:21] SPEAKER_02: Anyone who has questions, don't hesitate to put them in the
[22:24] SPEAKER_02: message here, and we'll try to get to them as we go along.
[22:28] SPEAKER_02: Now,
[22:28] the next topic I wanted to get into after you kind of get a
[22:34] sense about your risk,
[22:35] SPEAKER_02: and by the way,
[22:35] SPEAKER_02: before I leave that,
[22:37] SPEAKER_02: Chris Everett in your book has a wonderful quote.
[22:41] SPEAKER_02: I just wanted to scream out on top of the mountain about genetic testing,
[22:46] SPEAKER_02: family history,
[22:47] SPEAKER_02: and early screening.
[22:50] She was reflecting on her diagnosis and the critical importance
[22:53] of uncovering genetic risks.
[22:56] SPEAKER_02: And by the way, there's a lot more breast cancer among young women now.
[23:01] Even those younger than age 40 where you advocate for the start
[23:06] of mammography.
[23:08] SPEAKER_02: What do you think is going on then?
[23:10] I,
[23:10] gosh,
[23:11] you know,
[23:11] it's really,
[23:12] really,
[23:13] I've seen in my office in the last six months,
[23:16] a number of women diagnosed with breast cancer in their 20s and
[23:20] it's really really
[23:22] upsetting disturbing all those things and what's weird is that
[23:26] well of course it's
[23:28] SPEAKER_00: incredibly crushing to discover Eric that they've had an unknown disease
[23:33] SPEAKER_00: Bracken Mutation and that's what's causing it.
[23:36] But there are a fair amount of women who are getting it without
[23:39] that Bracken
[23:39] SPEAKER_00: Mutation where we're scratching our heads going,
[23:42] SPEAKER_00: I don't know why.
[23:43] SPEAKER_00: I have a 28-year-old who came in a couple weeks ago,
[23:45] SPEAKER_00: no family history,
[23:47] SPEAKER_00: no genetic mutations,
[23:48] SPEAKER_00: and it leaves us scratching our head.
[23:51] You know,
[23:52] the hypotheses that I talk about in the book,
[23:55] no one knows for sure.
[23:57] But of course,
[23:58] you know,
[23:58] we talk about the obesity epidemic in this country.
[24:01] SPEAKER_00: You know,
[24:01] what's interesting is right now about 30 to 40 percent of our
[24:05] adult population is
[24:06] SPEAKER_00: obese.
[24:07] SPEAKER_00: But
[24:08] SPEAKER_00: 20% of our youngsters between 12 and 19 are now overweight and obese.
[24:17] So let's go back to the part we were talking about related to
[24:20] hormones and fat stores.
[24:25] SPEAKER_00: And early onset,
[24:27] SPEAKER_00: we worry that there's also the age at what we call menarche,
[24:32] SPEAKER_00: when young women start to get their periods is also declining.
[24:36] SPEAKER_00: And the interrelationship with that and obesity, we're not really sure.
[24:41] SPEAKER_00: You know,
[24:42] SPEAKER_00: in the 1800s,
[24:43] SPEAKER_00: women used to get their period,
[24:45] SPEAKER_00: the average woman got her period at like 17 for the first time.
[24:48] SPEAKER_00: By the 1950s or 60s, it was like 13.
[24:51] SPEAKER_00: And now it's hovering around 11.9 or young 12.
[24:54] SPEAKER_00: Wow.
[25:01] SPEAKER_00: Why do I bring that up?
[25:02] SPEAKER_00: Because the earlier you get your period,
[25:05] the higher the risk of breast cancer by a small amount because
[25:08] it's the number of
[25:09] SPEAKER_00: hormonal cycles your breasts are exposed to.
[25:13] SPEAKER_00: So the interrelationship,
[25:14] SPEAKER_00: whether it's the drop in the age of menarche related to obesity,
[25:20] SPEAKER_00: not related to obesity,
[25:22] SPEAKER_00: some triangle between the three—
[25:25] SPEAKER_00: is really, I think, one of the hypotheses.
[25:29] SPEAKER_00: Obviously,
[25:30] people talk all the time about dietary factors and our diets
[25:34] and processed food
[25:36] SPEAKER_00: and...
[25:37] SPEAKER_00: And hormones in our food,
[25:39] SPEAKER_00: honestly,
[25:40] SPEAKER_00: I'm not sure hormones in milk can survive stomach acid,
[25:45] SPEAKER_00: so you would know better than me.
[25:46] SPEAKER_00: So I just don't,
[25:49] SPEAKER_00: I don't know,
[25:50] SPEAKER_00: you know,
[25:51] SPEAKER_00: what the environmental exposures are here,
[25:55] SPEAKER_00: but we do see it and we do have to,
[25:58] SPEAKER_00: you know,
[25:59] We Do Have To Be Aware Of It And Look I Always Say There's A
[26:03] Whole Chapter In The
[26:04] Book As A Young Woman I Don't Care How Old You Are 18 19 20 21
[26:08] 22 If You Feel
[26:10] Something You Say Something There's A Whole Chapter Entitled If
[26:13] You Feel Something
[26:14] Say Something Right We Say In New York City If You See
[26:17] Something Say Something
[26:18] SPEAKER_00: Related To Crime
[26:19] If you feel something in your body,
[26:22] you know,
[26:22] be an advocate for yourself.
[26:23] SPEAKER_00: Say something.
[26:24] SPEAKER_00: Don't let someone dismiss you.
[26:26] SPEAKER_00: Don't let anyone ever use my least favorite phrase on the planet,
[26:32] SPEAKER_00: you're too young to get breast cancer.
[26:35] SPEAKER_00: Never, never, never, never.
[26:37] SPEAKER_00: Right?
[26:38] SPEAKER_02: Right.
[26:39] SPEAKER_02: Absolutely.
[26:39] SPEAKER_02: Now, Barbara's asking about hormone replacement.
[26:42] SPEAKER_02: We're going to get to that in a minute.
[26:44] SPEAKER_02: I do want to get to the mammograms and screenings.
[26:49] SPEAKER_02: So what is really,
[26:52] SPEAKER_02: again,
[26:52] to me crazy here is we screen only 12% of women are ever going
[26:59] to get breast
[26:59] SPEAKER_02: cancer,
[27:00] SPEAKER_02: but they're all coming supposedly on a very frequent basis,
[27:03] SPEAKER_02: age 40,
[27:04] SPEAKER_02: possibly even younger if they have their own risk,
[27:08] SPEAKER_02: which 90% have no family history,
[27:12] SPEAKER_02: who are showing up eventually with breast cancer.
[27:15] SPEAKER_02: So we have this kind of
[27:18] SPEAKER_02: Blind,
[27:19] SPEAKER_02: huge blind spot of on the same time people are talking about why not have
[27:24] SPEAKER_02: risk-based screening?
[27:27] That is,
[27:28] if we only took people who had low risk and gave them,
[27:32] you know,
[27:34] infrequent,
[27:36] SPEAKER_02: because the mammograms are often leading us astray.
[27:41] SPEAKER_02: That is,
[27:42] SPEAKER_02: there's so many false positives,
[27:43] SPEAKER_02: so many biopsies based on the mammograms,
[27:46] SPEAKER_02: and then we'll get into,
[27:47] SPEAKER_02: you know,
[27:48] SPEAKER_02: dense breasts and how that's even more of a problem.
[27:52] SPEAKER_02: And, you know, this is a mess.
[27:57] SPEAKER_02: The percent of false positives in the procedures,
[28:01] it's no wonder that a lot of women don't ever want to go for
[28:03] any mammogram.
[28:05] SPEAKER_02: So do you think that the way we do today,
[28:09] SPEAKER_02: of course,
[28:10] we're going to get into all these AI tools that are being used
[28:14] at Mount Sinai at no
[28:15] SPEAKER_02: cost to women,
[28:17] SPEAKER_02: but outside of Mount Sinai,
[28:19] I don't know too many places that are providing at least one of
[28:21] the three AI tools
[28:22] SPEAKER_02: that I'm keen on,
[28:24] SPEAKER_02: but this idea of treating,
[28:26] SPEAKER_02: again,
[28:27] SPEAKER_02: all women the same with an
[28:29] SPEAKER_02: Mammograms are not perfect.
[28:30] SPEAKER_02: No one ever said they were.
[28:58] SPEAKER_00: But they do,
[28:59] SPEAKER_00: in women with non-dense breasts,
[29:02] SPEAKER_00: they do pick up about 80% to 90% of breast cancers.
[29:06] So they are still the most effective screening test for a large
[29:11] population.
[29:13] That definitely will get to women with dense breasts and why
[29:17] we're missing the boat on so many.
[29:19] SPEAKER_00: And it's the thing we have the most data on.
[29:22] SPEAKER_00: They're the only test proven, Eric.
[29:25] SPEAKER_00: to reduce mortality from breast cancer by picking it up early.
[29:32] We did an incredible study at Mount Sinai where we took women
[29:36] who walked through
[29:36] SPEAKER_00: our door with a breast cancer diagnosis.
[29:41] We already know that women who get screened have a 15% to 30%
[29:45] lower risk of dying
[29:47] SPEAKER_00: from breast cancer because of early detection.
[29:49] SPEAKER_00: But the study that we did at Mount Sinai,
[29:51] SPEAKER_00: which was super interesting,
[29:52] is we took everyone that walked into our center with breast
[29:54] cancer and we put them
[29:55] SPEAKER_00: in one of three groups.
[29:58] Group one is women who had had a mammogram within the past like
[30:01] two years,
[30:01] SPEAKER_00: so relatively recently screened.
[30:04] Group 2 had had a mammogram at some point,
[30:06] but more than two years,
[30:08] so not recent.
[30:09] SPEAKER_00: And Group 3,
[30:09] SPEAKER_00: believe it or not,
[30:10] SPEAKER_00: there are people who had never had a mammogram,
[30:12] SPEAKER_00: as you pointed out,
[30:13] SPEAKER_00: okay?
[30:14] SPEAKER_00: When you compare Group 1,
[30:15] the people who had a mammogram within the last two years
[30:18] compared to the other two
[30:20] SPEAKER_00: groups who weren't really being regularly screened,
[30:23] SPEAKER_00: you were way more likely,
[30:26] SPEAKER_00: if you were in the screened group,
[30:30] SPEAKER_00: to not need chemotherapy
[30:33] to not need a mastectomy because your cancer was so much
[30:37] smaller and to not need a
[30:39] lot more aggressive treatments like all your lymph nodes
[30:42] removed and so forth.
[30:44] So the one other benefit I want to point out for mammograms
[30:47] before we completely
[30:48] SPEAKER_00: like throw it under the bus is that not only do they save lives,
[30:53] SPEAKER_00: but they save lives allowing us to do less,
[30:56] SPEAKER_00: less aggressive treatment,
[30:57] SPEAKER_00: which helps
[30:59] SPEAKER_00: All of us want for our patients, okay?
[31:02] SPEAKER_00: It leads to a lot of biopsies, though, right?
[31:03] SPEAKER_00: Okay, so let's talk about that.
[31:06] SPEAKER_00: One of the very,
[31:09] SPEAKER_00: very big misconceptions,
[31:11] SPEAKER_00: so mammograms lead to callbacks in about 10% of cases,
[31:16] SPEAKER_00: okay?
[31:17] SPEAKER_00: Here's something that very few people understand.
[31:20] SPEAKER_00: Most callbacks, 80% to 90%, are resolved with additional pictures only.
[31:27] SPEAKER_00: And no biopsy is needed.
[31:29] SPEAKER_00: Okay,
[31:30] SPEAKER_00: so while mammograms can be very,
[31:32] SPEAKER_00: you know,
[31:33] SPEAKER_00: can lead to a lot of anxiety,
[31:34] SPEAKER_00: and when you get that call saying,
[31:36] SPEAKER_00: come back in,
[31:37] take a deep breath and know that there's a very high chance
[31:41] that it will be like,
[31:42] SPEAKER_00: okay,
[31:43] SPEAKER_00: I didn't get back far enough,
[31:45] SPEAKER_00: now I have,
[31:46] SPEAKER_00: and I got a better picture and I pressed a little harder,
[31:49] SPEAKER_00: and you're fine.
[31:50] SPEAKER_00: So,
[31:51] SPEAKER_00: I would say biopsy is kind of a last resort, okay?
[31:55] SPEAKER_00: And yes,
[31:56] SPEAKER_00: there are a lot of what we call false positives,
[31:59] SPEAKER_00: but if you go back in,
[32:01] SPEAKER_00: you're called back,
[32:03] SPEAKER_00: most of those things will not require a biopsy.
[32:05] SPEAKER_00: But,
[32:07] SPEAKER_02: I mean,
[32:07] SPEAKER_02: you might want to comment,
[32:08] SPEAKER_02: before we get into the AI helping this out,
[32:13] SPEAKER_02: a study of 10,000 women age 50 who came back every year,
[32:20] 60% cumulative over 10 years from age 50 to 60 of false
[32:25] positive mammograms.
[32:27] SPEAKER_00: But the false positive doesn't mean you end up with a biopsy.
[32:31] SPEAKER_00: A lot of them just ended up getting called back in for more pictures.
[32:35] SPEAKER_02: Right.
[32:36] SPEAKER_02: Over a 10-year period, a lot will get called in.
[32:38] SPEAKER_00: We'll get called back and say, look, I didn't get a good enough view.
[32:41] SPEAKER_00: And,
[32:42] SPEAKER_00: you know,
[32:42] SPEAKER_00: the false positive definition is a very big wastebasket,
[32:45] SPEAKER_00: everything from an invasive procedure from a biopsy.
[32:48] SPEAKER_00: You know, what I would say is that you're 100% right.
[32:51] That's why we try to improve technology so that,
[32:56] you know,
[32:56] 3D is much better.
[32:58] You know,
[32:59] for example,
[32:59] one of the biggest advantages of 3D was not picking up more
[33:03] cameras.
[33:03] SPEAKER_00: Yeah.
[33:24] I'm not going to challenge that it's the best screening test to
[33:26] start with,
[33:27] SPEAKER_00: but I'm going to try to build on how we can do better.
[33:30] SPEAKER_00: Before I do that...
[33:52] You know,
[33:53] this issue of the,
[33:57] well,
[33:58] what proportion of women have in the dense breast category?
[34:06] SPEAKER_02: That's a pretty substantial, depending on how you define it, right?
[34:11] SPEAKER_00: Yeah, I think it really depends, Eric, on age group.
[34:14] SPEAKER_00: Like probably you're right.
[34:15] When you start getting your mammograms at age 40 based on the
[34:18] recommendations,
[34:20] SPEAKER_00: about 50% of women,
[34:21] SPEAKER_00: 40 to 50% are going to have dense breasts and probably need,
[34:26] SPEAKER_00: you're right,
[34:27] SPEAKER_00: in that group,
[34:28] SPEAKER_00: ironically,
[34:29] SPEAKER_00: the sensitivity of mammograms go down.
[34:32] SPEAKER_00: And so you want to add on an ultrasound, okay?
[34:36] SPEAKER_00: And look,
[34:37] SPEAKER_00: Ultrasounds can pick up cancers that mammograms miss,
[34:42] SPEAKER_00: and I see those in my office every single week.
[34:46] What I would say is ultrasound is not the best screening tool
[34:49] because what a lot of
[34:50] SPEAKER_00: people don't realize is ultrasound is a very operator-dependent test.
[34:54] SPEAKER_00: So you can miss spots.
[34:56] SPEAKER_00: You know,
[34:56] SPEAKER_00: you have someone kind of like,
[34:58] SPEAKER_00: I call it almost painting the surface of the breast,
[35:01] SPEAKER_00: and you can miss spots.
[35:03] SPEAKER_00: It's not as comprehensive a view the way a mammogram can.
[35:07] And if you want to talk about a test that generates false
[35:10] positives and generates
[35:11] SPEAKER_00: biopsies,
[35:12] SPEAKER_00: ultrasound is definitely right up there too.
[35:15] SPEAKER_00: You brought up MRI, which is a really important tool.
[35:20] SPEAKER_00: We generally reserve MRI
[35:24] SPEAKER_00: for screening in high-risk populations because,
[35:28] SPEAKER_00: again,
[35:29] the MRI is probably the most sensitive and generates the most
[35:34] false positive
[35:35] SPEAKER_00: findings.
[35:36] SPEAKER_00: So who are the people where you say,
[35:39] SPEAKER_00: look,
[35:39] I'm willing to take a few more false positive findings to make
[35:43] sure I don't miss a
[35:44] SPEAKER_00: cancer?
[35:45] SPEAKER_00: Generally, the highest risk groups.
[35:47] And the way you define that,
[35:49] just to give the audience kind of like very clear boundaries,
[35:52] SPEAKER_00: The average woman's risk of getting breast cancer,
[35:54] SPEAKER_00: as you said,
[35:54] SPEAKER_00: is about 10% to 12% over her lifetime,
[35:57] SPEAKER_00: okay?
[35:59] SPEAKER_00: 10% to 12% to 19% is considered intermediate risk,
[36:05] SPEAKER_00: and 20% or higher is categorized or defined as higher risk.
[36:12] SPEAKER_00: And why is that number important?
[36:14] Because that's the number at which most insurance companies
[36:20] will agree to pay for
[36:22] SPEAKER_00: added screening,
[36:23] SPEAKER_00: MRI screening.
[36:25] SPEAKER_00: And women say, well, how do I know?
[36:27] SPEAKER_00: How do I know if I'm 20%?
[36:29] This gets back to what we were talking about with the risk
[36:33] calculators that are
[36:34] online that are not perfect but are effective at least to get a
[36:38] ballpark risk,
[36:40] SPEAKER_00: you know,
[36:41] SPEAKER_00: of what.
[36:42] SPEAKER_00: And it'll tell you,
[36:43] SPEAKER_00: you know,
[36:43] there are these models online called Tyra Kuzik or it's called
[36:46] the Breast Cancer
[36:47] SPEAKER_00: Risk Assessment Tool if you just Google it.
[36:49] And any human can go in there and plug in all their factors and
[36:53] it spits out a number.
[36:55] And doctors should be doing this more often,
[36:59] OBGYNs,
[37:00] primary care doctors,
[37:01] to define risk.
[37:02] SPEAKER_00: And every once in a while, a 20-25 percenter will pop up.
[37:07] And then you have to have the conversation about,
[37:10] should I be getting MRI on top of mammograms?
[37:13] SPEAKER_02: Yeah.
[37:14] SPEAKER_02: Now, as you emphasize in the book, dense breast is more of a challenge.
[37:19] SPEAKER_02: It's like finding a polar bear.
[37:21] SPEAKER_02: No storm is in the book.
[37:23] SPEAKER_02: But now I want to talk about AI because,
[37:26] SPEAKER_02: as you know,
[37:27] the largest trial ever in the history of medical AI was
[37:30] performed with mammograms.
[37:32] Over 100,000 women in Sweden,
[37:34] they either had two radiologists or one radiologist with an AI.
[37:40] SPEAKER_02: Transpara AI.
[37:43] SPEAKER_02: Same algorithm used at Mount Sinai.
[37:46] SPEAKER_02: Now,
[37:46] that trial not only showed almost 30% higher detection of
[37:52] breast cancer with the AI
[37:54] SPEAKER_02: arm and no increase in callbacks,
[37:59] SPEAKER_02: and during two-year follow-up recently published,
[38:03] SPEAKER_02: it picked up,
[38:03] SPEAKER_02: and because of the higher pickup early,
[38:06] SPEAKER_02: it had less
[38:08] SPEAKER_02: cancer that is prevention during follow-up.
[38:11] SPEAKER_00: Exactly.
[38:11] SPEAKER_00: In what's called the intervals.
[38:13] SPEAKER_02: Yeah.
[38:14] SPEAKER_02: Yeah.
[38:14] And not only that,
[38:16] but there's two other AIs,
[38:17] right,
[38:18] that are not being used.
[38:19] SPEAKER_02: There's Clarity.
[38:21] SPEAKER_02: Well, yeah.
[38:22] SPEAKER_02: Clarity and the other folks at Mass General MRI.
[38:28] SPEAKER_02: But here, Clarity is FDA approved.
[38:31] SPEAKER_02: And for a normal mammogram, it will still say
[38:35] to the patient,
[38:36] you have a high risk in the next three to five years,
[38:39] FDA approved.
[38:40] SPEAKER_02: And there's a third one from Curemetrics.
[38:43] I wrote about this in a ground truth about the three AI tools
[38:46] that are not being
[38:46] SPEAKER_02: used and it drives me nuts that it's not being used.
[38:49] SPEAKER_00: And the only one that drives me nuts too.
[38:52] SPEAKER_00: I agree with you.
[38:53] SPEAKER_02: The third one is Curemetrics, which gives you the
[38:56] Breast Artery Calcification Heart Risk What's really amazing is
[39:02] these are all
[39:03] SPEAKER_02: validated,
[39:04] SPEAKER_02: very careful studies,
[39:05] SPEAKER_02: right?
[39:05] SPEAKER_02: Especially the Transpara AI algorithm.
[39:09] SPEAKER_02: And they're not available in most centers.
[39:12] And when they are available in the limited ones,
[39:16] like RadNet,
[39:17] you have to pay
[39:18] SPEAKER_02: Just for the one,
[39:20] SPEAKER_02: the detection one,
[39:22] SPEAKER_02: not the prevention or the heart risk,
[39:24] SPEAKER_02: you have to pay out-of-pocket $40.
[39:26] SPEAKER_02: Now, this is crazy.
[39:28] SPEAKER_02: I know you don't charge for this at Mount Sinai, so how do you do that?
[39:33] SPEAKER_00: Yeah, you know, I want to just start by saying this was a vision.
[39:37] SPEAKER_00: You know,
[39:37] SPEAKER_00: Mount Sinai,
[39:38] we have one of the most diverse patient populations possibly in
[39:42] the world.
[39:43] SPEAKER_00: I always say, you know, one door in the center
[39:47] SPEAKER_00: is on Fifth Avenue,
[39:50] SPEAKER_00: which most people across the country,
[39:52] SPEAKER_00: across the world know is very ritzy,
[39:53] and there's apartments that are two blocks down that are
[39:56] probably tens of millions
[39:58] SPEAKER_00: of dollars.
[39:59] SPEAKER_00: On the other side, we have housing projects, okay?
[40:02] And my center is right in the middle of both the Upper East
[40:06] Side and a neighborhood
[40:08] SPEAKER_00: called East Harlem.
[40:10] SPEAKER_00: And
[40:11] SPEAKER_00: Here's the thing,
[40:12] our model was established that everyone gets the same level of
[40:15] care regardless of
[40:17] SPEAKER_00: ability to pay.
[40:18] We take care of very wealthy people and celebrities and we take
[40:22] care of poor people
[40:25] SPEAKER_00: and homeless people and everyone in between.
[40:28] And so that was the model that we set up and I'm super proud of
[40:32] that and that is
[40:33] SPEAKER_00: part of my ethos and part of my commitment.
[40:37] SPEAKER_00: And so
[40:39] You start from that and say,
[40:40] I'm not going to offer a service that only some people can
[40:45] afford.
[40:46] SPEAKER_00: And you work back from that.
[40:48] And we raise a lot of money in philanthropy that covers costs
[40:51] and things like that.
[40:53] SPEAKER_00: There is insurance reimbursement for some of it.
[40:57] And I think it's just a difference that some places look at it
[41:02] as a business
[41:03] SPEAKER_00: opportunity and we don't.
[41:05] SPEAKER_00: You know, you can get reimbursement for some of these things.
[41:10] SPEAKER_00: And we don't look at it that way.
[41:11] SPEAKER_00: Like, you know, why would I charge your patient $40?
[41:15] SPEAKER_00: And I think,
[41:16] SPEAKER_00: you know,
[41:16] when I can do it and it's better service and I can pay for it
[41:21] in other ways,
[41:23] whether it's through insurance reimbursement and the patient
[41:25] doesn't have to bear
[41:26] SPEAKER_00: the brunt of the cost,
[41:27] SPEAKER_00: especially if they can't afford it.
[41:30] SPEAKER_00: So I think that as these,
[41:33] SPEAKER_00: to your point,
[41:35] SPEAKER_00: as these technologies proliferate,
[41:38] it will be more common knowledge that you can get them added on
[41:43] as part of standard
[41:45] SPEAKER_00: of care,
[41:46] SPEAKER_00: right?
[41:46] SPEAKER_00: As we are doing.
[41:49] SPEAKER_00: And we're seeing like,
[41:50] SPEAKER_00: you know,
[41:50] SPEAKER_00: tremendous results,
[41:52] SPEAKER_00: very much reflective of the data that you shared from the big,
[41:56] SPEAKER_00: you know,
[41:56] SPEAKER_00: Swedish study.
[41:57] SPEAKER_00: I do think it's important to know,
[41:59] SPEAKER_00: to put into perspective,
[42:01] SPEAKER_00: you know,
[42:01] when we throw around these numbers like increase in 30% and
[42:04] decrease in 20% or
[42:06] SPEAKER_00: whatever,
[42:06] SPEAKER_00: remember,
[42:08] what that means is that make believe you do a mammogram and you
[42:13] do a thousand
[42:14] SPEAKER_00: mammograms and you pick up
[42:16] SPEAKER_00: 10 cancers, okay?
[42:20] Increasing detection rate by 30% means now you've picked up 13
[42:26] cancers,
[42:27] not 40.
[42:29] SPEAKER_00: And so I do want to make sure,
[42:31] SPEAKER_00: and let's just agree that for those three people,
[42:34] SPEAKER_00: it's really,
[42:35] SPEAKER_00: really important.
[42:36] SPEAKER_00: It's life-changing and life-saving.
[42:39] SPEAKER_00: But we're talking about really
[42:42] Improving every one of these things marginally improves on what
[42:47] we had before.
[42:48] SPEAKER_00: It was,
[42:48] SPEAKER_00: you know,
[42:48] SPEAKER_00: first it was,
[42:50] SPEAKER_00: listen,
[42:50] I'm old enough to have gone into practice when people walked
[42:53] into their office with
[42:54] SPEAKER_00: like a jacket of x-rays.
[42:56] Like young people on this,
[42:58] on the Substack are like,
[43:00] what is she talking about?
[43:01] SPEAKER_00: Like, and then they came in with like literally film and doctors had
[43:07] view light boxes and we would put the films up and look at them
[43:11] together like we
[43:12] SPEAKER_00: haven't done that in 20 years then it went to digital and
[43:16] Then it went to where you'd come in with a disk Then it went to
[43:19] 3D And now we're at
[43:22] SPEAKER_00: AI Which is,
[43:24] SPEAKER_00: yes,
[43:24] SPEAKER_00: you know And we're still learning from AI,
[43:27] SPEAKER_00: right?
[43:27] We're still learning But I couldn't agree with you more This is
[43:31] state-of-the-art I
[43:32] SPEAKER_00: happen to work with a super visionary Leader in breast imaging,
[43:37] SPEAKER_00: Laurie Margulies Who has spearheaded all of this stuff And has really,
[43:41] SPEAKER_00: really been incredibly proactive about it
[43:45] even the breast arterial calcification stuff and reporting on
[43:49] that you know as it
[43:50] relates to heart like we there's an incredible news story I'd
[43:54] invite people to
[43:55] google it where a woman came in on her when we first started
[43:59] reporting breast
[44:00] arterial calcification woman came in completely asymptomatic
[44:05] had a mammogram we
[44:06] wrote in the report you may want to see your doctor about this
[44:10] you know you have
[44:10] SPEAKER_00: breast arterial
[44:13] SPEAKER_00: She called the radiology office like, I don't have a cardiologist.
[44:16] SPEAKER_00: What should I do?
[44:16] SPEAKER_00: We sent her to cardiology.
[44:18] SPEAKER_00: She got into a stress test,
[44:20] SPEAKER_00: failed the stress test,
[44:21] SPEAKER_00: and was immediately taken for bypass surgery like a day or two later.
[44:26] SPEAKER_00: Obviously,
[44:27] SPEAKER_00: I'm sure as a cardiologist,
[44:29] you've seen numerous examples of these people who are
[44:33] completely asymptomatic and
[44:35] SPEAKER_00: are just ticking time bombs.
[44:38] SPEAKER_00: Absolutely.
[44:39] and if you google the story this woman was on a national news
[44:43] story with Lori
[44:44] showing how like a mammogram her story is a mammogram saved my
[44:47] life and is not from
[44:48] SPEAKER_00: breast cancer
[44:49] SPEAKER_02: Exactly.
[44:50] SPEAKER_02: We call it opportunistic screening.
[44:52] And we're leaving all this stuff on the table that is easy to
[44:56] read that out.
[44:58] SPEAKER_02: And it usually is not part of the radiologist's readout of a mammogram.
[45:02] SPEAKER_02: But what's interesting,
[45:03] SPEAKER_02: just a footnote here,
[45:05] SPEAKER_02: that most women are worried mostly about breast cancer.
[45:09] SPEAKER_02: Their highest risk is actually heart disease.
[45:12] SPEAKER_02: 100%.
[45:13] SPEAKER_02: Easy way to get to that.
[45:15] SPEAKER_02: Now, so that's making the mammogram better, actually.
[45:18] SPEAKER_02: It's giving you a window into a whole other important disease process.
[45:24] Now,
[45:26] I want to come back to hormone replacement therapy,
[45:30] birth control pills.
[45:31] SPEAKER_02: This is something Barbara Sipper brought up.
[45:35] SPEAKER_02: But again, if you knew the risk of a person,
[45:40] SPEAKER_02: You might use these things a little differently, right?
[45:42] But since there's not,
[45:44] and I'm actually a big advocate of polygenic risk scores.
[45:47] SPEAKER_02: I know you think they're not ready.
[45:48] SPEAKER_02: Okay, but sequencing, you can do that.
[45:51] SPEAKER_02: It's now down to,
[45:52] SPEAKER_02: you know,
[45:53] SPEAKER_02: if you go to the right place,
[45:54] SPEAKER_02: you can get a full whole genome sequence now.
[45:57] SPEAKER_02: Very inexpensive, less than a usual lab test, but it's not being done.
[46:02] SPEAKER_02: So what about this?
[46:04] SPEAKER_02: You know, is hormone replacement therapy in postmenopausal women
[46:10] SPEAKER_02: Eric Topol erictopol
[46:19] SPEAKER_00: So let's talk about HRT first.
[46:21] SPEAKER_00: As you know,
[46:21] SPEAKER_00: this is a super hot topic,
[46:23] SPEAKER_00: topical issue because of the whole FDA removing the black box last year.
[46:29] SPEAKER_00: So look, let's talk about the history.
[46:33] HRT was being used for years very liberally to quell menopausal
[46:39] symptoms and it's
[46:40] SPEAKER_00: super effective,
[46:41] SPEAKER_00: okay?
[46:43] SPEAKER_00: And it is a great tool to deal with
[46:47] Almost Every Menopausal Side Effect Whether It's Hot Flashes
[46:50] Vaginal Dryness
[46:52] Cognitive Effects Etc There's So Many Factors That Really
[46:57] Affect Women's Quality Of
[46:58] Life Then The Women's Health Study Came Out Right I Know You're
[47:04] Shaking Your Head
[47:05] SPEAKER_00: I'm About To As Well And It
[47:08] Basically changed things overnight because it reported an
[47:13] increased risk of breast
[47:14] SPEAKER_00: cancer,
[47:15] SPEAKER_00: an increased risk of cardiovascular disease,
[47:18] SPEAKER_00: and many other things that led to,
[47:20] SPEAKER_00: number one,
[47:22] SPEAKER_00: a steep drop off in doctors willing to prescribe it.
[47:27] Some drop off in women taking it and basically a black box
[47:34] label warning being
[47:36] SPEAKER_00: placed on these medications,
[47:37] SPEAKER_00: which if anyone wants to understand a black box,
[47:40] SPEAKER_00: it's really scary.
[47:41] SPEAKER_00: It's like the highest level of risk that you can give a medication,
[47:46] SPEAKER_00: which I think was an extreme overreaction.
[47:50] SPEAKER_00: Why?
[47:51] SPEAKER_00: Because the study was...
[47:53] SPEAKER_00: Flawed in many ways.
[47:55] SPEAKER_00: You know, these women were started on HRT in their 60s.
[48:00] SPEAKER_00: What women, why would you ever start someone on HRT in your 60s?
[48:05] SPEAKER_00: The ship has sailed.
[48:06] You've already suffered through all the menopausal symptoms
[48:09] when you're 47,
[48:10] 48,
[48:11] 50,
[48:11] whatever.
[48:12] SPEAKER_00: So for sure,
[48:13] the risk of the heart disease and the breast cancer is going to
[48:17] be greater in that
[48:19] SPEAKER_00: older group.
[48:21] SPEAKER_00: I will say one thing.
[48:24] SPEAKER_00: In the wake of the women's health study,
[48:29] SPEAKER_00: you know,
[48:29] SPEAKER_00: the incidence of breast cancer in this country did go down.
[48:34] As women stopped taking hormone replacement therapy,
[48:37] the incidence of breast cancer did go down.
[48:40] SPEAKER_00: And we saw that.
[48:42] Fast forward to 2025 now where the black box label has been
[48:47] removed and the
[48:49] pendulum has swung it in the other direction where we're saying
[48:52] everyone should be
[48:53] SPEAKER_00: on it.
[48:53] SPEAKER_00: and there are no risks and that's just not true.
[48:57] I agree that hormone replacement therapy is an amazing tool to
[49:01] deal with quality of
[49:02] SPEAKER_00: life issues and women should be offered it and it's a very personalized,
[49:07] SPEAKER_00: individualized conversation.
[49:08] SPEAKER_00: However, here's what we need to know.
[49:11] Estrogen alone does not increase the risk of breast cancer but
[49:16] you can't really
[49:17] take it because it increases the risk of uterine cancer if you
[49:21] have a uterus,
[49:23] SPEAKER_00: okay?
[49:24] SPEAKER_00: That's called unopposed estrogen.
[49:28] SPEAKER_00: Estrogen plus progesterone
[49:31] has no increased risk of uterine cancer,
[49:33] but it does increase breast cancer risk.
[49:36] SPEAKER_00: And that is what most people on the combined therapy.
[49:40] But again,
[49:41] let's go back to our discussion about 20% and 15% and how much
[49:45] does it increase risk?
[49:47] If we already talked about the average woman's risk of getting
[49:49] breast cancer is 10%
[49:50] SPEAKER_00: to 12%,
[49:51] SPEAKER_00: and we say hormone replacement therapy increases risk by 20%,
[49:55] SPEAKER_00: now we're talking about
[49:57] SPEAKER_00: 12 to 14%, not 30%, as a lot of women think, right?
[50:03] A lot of women think that if you take a risk of 10% and you add
[50:06] a risk of 20%,
[50:07] SPEAKER_00: that gets you to 30%.
[50:09] SPEAKER_00: That's a big number and that's pretty prohibitive.
[50:12] I don't know a lot of women who would want to take hormone
[50:14] replacement therapy if
[50:15] SPEAKER_00: their risk of breast cancer was one in three,
[50:18] SPEAKER_00: right?
[50:19] SPEAKER_00: But if you take it at 10%,
[50:23] SPEAKER_00: and say, oh, I'm increasing my risk to 12%.
[50:27] SPEAKER_00: That's a very marginal increased risk.
[50:30] SPEAKER_00: And so I think...
[50:32] SPEAKER_00: We have to be very honest about how we portray these risks.
[50:36] SPEAKER_00: There is an increased risk, but it's very marginal.
[50:40] SPEAKER_00: And also, it's incremental depending on how long you're on it.
[50:45] So a lot of women go on hormone replacement therapy for three
[50:48] or five years or
[50:49] SPEAKER_00: whatever,
[50:50] SPEAKER_00: you know,
[50:51] SPEAKER_00: to get them over the hump of menopausal symptoms.
[50:53] SPEAKER_00: That risk is less than 10 years, which is less than 20 years.
[50:57] SPEAKER_00: And so I'm a really big fan of the medication's
[51:01] SPEAKER_00: for women who feel like they're suffering, you know, and need it.
[51:07] SPEAKER_00: Unfortunately,
[51:08] SPEAKER_00: the one main group,
[51:09] SPEAKER_00: and even women at increased risk for breast cancer,
[51:14] SPEAKER_00: consider this medication on a
[51:17] SPEAKER_00: I think the hard stop is still women who've actually had breast cancer.
[51:23] SPEAKER_00: You know, most breast cancer is hormonally fed.
[51:26] And so that's still pretty much a no-fly zone for hormone
[51:31] replacement therapy.
[51:33] SPEAKER_00: There are newer formulations that are being worked on.
[51:37] SPEAKER_00: You know, many women who are
[51:39] SPEAKER_00: who've had breast cancer on anti-hormonal medications.
[51:44] SPEAKER_00: So they can't take hormones.
[51:45] SPEAKER_00: You can't take hormones and anti-hormonants.
[51:47] SPEAKER_00: So that's where we land.
[51:50] SPEAKER_00: I'm a very,
[51:50] SPEAKER_00: very big believer in hormone replacement therapy as a very,
[51:53] SPEAKER_00: very important tool for women.
[51:56] SPEAKER_00: But I do think to say it has no risks is...
[52:01] SPEAKER_00: is not doing women a service.
[52:04] SPEAKER_00: As it relates to birth control pills,
[52:06] SPEAKER_00: the pretty much like the study you quoted,
[52:08] SPEAKER_00: the most definitive study came out of,
[52:11] SPEAKER_00: as usual,
[52:12] SPEAKER_00: Scandinavia,
[52:12] SPEAKER_00: where they have very,
[52:13] SPEAKER_00: very detailed records.
[52:15] SPEAKER_00: And
[52:17] SPEAKER_00: In a million Danish women,
[52:18] SPEAKER_00: it showed that,
[52:19] SPEAKER_00: yes,
[52:20] SPEAKER_00: hormones from birth control pills do marginally,
[52:23] SPEAKER_00: again,
[52:24] SPEAKER_00: increase the risk of breast cancer.
[52:26] SPEAKER_00: And again, it's a dose-response effect.
[52:29] SPEAKER_00: If you take it for one year, it's almost nothing.
[52:31] SPEAKER_00: Five years, 10 years, 20 years, etc.
[52:34] So I always say just,
[52:36] you know,
[52:36] be very,
[52:37] very individualized in your approach.
[52:39] And remember,
[52:40] birth control pills reduce the risk of other cancers that are
[52:44] more lethal.
[52:45] SPEAKER_00: So,
[52:46] SPEAKER_00: you know,
[52:47] SPEAKER_00: birth control pills reduced the risk of ovarian cancer and colon cancer,
[52:51] SPEAKER_00: which were way more lethal than breast cancer.
[52:55] SPEAKER_00: So I think those are really, these are all no one size fits all.
[52:59] And a woman should talk to her doctor and really talk about
[53:03] what her individual
[53:04] SPEAKER_00: concerns and risks are.
[53:07] SPEAKER_02: Sure.
[53:08] SPEAKER_02: Well, that's great.
[53:08] In fact,
[53:09] in the book,
[53:09] you made a very important point like you did earlier about
[53:13] Absolute versus Relative Risk Risk here of hormone replacement
[53:19] for breast cancer is
[53:20] SPEAKER_02: quite small,
[53:21] SPEAKER_02: even though we can't hear about the relative risk.
[53:23] SPEAKER_02: All right.
[53:24] Now,
[53:24] before we wrap up a couple of things,
[53:27] the prevention side,
[53:31] they're at high risk.
[53:33] SPEAKER_02: Now we want to go into prevent.
[53:35] SPEAKER_02: You already talked about lifestyle things with the four Ws.
[53:39] SPEAKER_02: Tamoxifen, D1,
[53:42] Tell us about what can you do if you're high risk from added
[53:46] medical interventions
[53:48] SPEAKER_02: like prescription-type drug.
[53:50] SPEAKER_00: Sure.
[53:52] SPEAKER_00: As you pointed out,
[53:54] tamoxifen is a medication we've been giving since the 70s for
[53:59] women with breast
[54:00] SPEAKER_00: cancer to reduce the risk of it coming back.
[54:04] SPEAKER_00: In the late 90s,
[54:05] SPEAKER_00: we started doing trials looking at whether or not that medication was,
[54:08] SPEAKER_00: hey,
[54:09] SPEAKER_00: if we can reduce the risk of it coming back...
[54:11] Can we give it to high-risk patients so that they never get it
[54:14] in the first place?
[54:15] SPEAKER_00: And the answer is yes.
[54:17] If you are at higher risk for getting breast cancer,
[54:20] make believe your risk is 25%.
[54:24] Tamoxifen in a high-risk person will reduce your risk of
[54:27] getting breast cancer by about half.
[54:31] SPEAKER_00: There are also really,
[54:32] SPEAKER_00: really,
[54:32] SPEAKER_00: interestingly,
[54:33] SPEAKER_00: there are certain groups,
[54:35] SPEAKER_00: Eric,
[54:35] SPEAKER_00: that by virtue of their risk,
[54:37] SPEAKER_00: you could reduce them even further.
[54:38] SPEAKER_00: So there's this entity,
[54:40] SPEAKER_00: I don't want to get too esoteric,
[54:42] but there's this entity where if you have a biopsy and it shows
[54:45] what's called
[54:45] SPEAKER_00: atypical cells,
[54:47] SPEAKER_00: you're at higher risk for getting breast cancer in the future.
[54:51] The tamoxifen in that group in the studies reduced the risk of
[54:55] those women getting
[54:56] SPEAKER_00: breast cancer by almost 80%.
[54:59] SPEAKER_00: So it is a really, really important tool.
[55:02] SPEAKER_00: Women for prevention typically take it for five years.
[55:07] We think it has another tail,
[55:09] like probably prevents for another five years beyond that.
[55:13] SPEAKER_00: So it can
[55:14] SPEAKER_00: And so on
[55:40] SPEAKER_00: You know,
[55:41] SPEAKER_00: I wrote one of the first papers on tamoxifen in the high-risk population,
[55:47] SPEAKER_00: and back in the early 2000s when we started offering it to people,
[55:52] SPEAKER_00: we thought it was going to be like people saying,
[55:54] SPEAKER_00: oh,
[55:54] SPEAKER_00: wow,
[55:55] SPEAKER_00: it reduces the risk of breast cancer by 50%.
[55:58] SPEAKER_00: Let's just put it in the drinking water.
[56:00] SPEAKER_00: Believe it or not, women were saying not so fast.
[56:03] SPEAKER_00: So the paper that we wrote was called Reluctance,
[56:06] SPEAKER_00: Patient Reluctance to Taking Tamoxifen for Primary Prevention.
[56:10] SPEAKER_00: And what we found is that, and this is nationally too, only about 20%.
[56:15] SPEAKER_00: 20-30% of women who are eligible to take it choose to do so.
[56:20] SPEAKER_00: They're nervous about side effects.
[56:22] We started this conversation with all medicines have side
[56:25] effects and tamoxifen has its.
[56:27] SPEAKER_00: So people feel like, wow, why would I reduce this to get this?
[56:33] SPEAKER_00: And so again, it's a very individualized decision.
[56:37] SPEAKER_02: Right.
[56:37] SPEAKER_02: And the GLP-1s,
[56:39] SPEAKER_02: as we were talking about before we started,
[56:41] SPEAKER_02: just today was a big paper about how they may wind up reducing in people,
[56:48] SPEAKER_02: women with breast cancer,
[56:49] SPEAKER_02: reducing recurrence,
[56:50] SPEAKER_02: improving survival.
[56:51] It's still not been established in a randomized trial,
[56:55] but it has a lot of promise,
[56:56] right?
[56:57] SPEAKER_00: I think a lot of promise.
[56:58] And people,
[56:59] you know,
[56:59] talk about not going on the GLP-1s and say,
[57:02] oh,
[57:02] gosh,
[57:03] you know,
[57:04] SPEAKER_00: They say two things, the skepticism about GLP-1s.
[57:08] SPEAKER_00: They say, why would I go on this?
[57:10] SPEAKER_00: Do I have to be on it forever?
[57:12] SPEAKER_00: And I counter with,
[57:14] SPEAKER_00: well,
[57:15] SPEAKER_00: when your doctor,
[57:16] SPEAKER_00: because you're overweight,
[57:17] SPEAKER_00: puts you on a cholesterol medication,
[57:19] SPEAKER_00: you know,
[57:20] you didn't ask them how long you're going to have to be on it
[57:22] because the answer is
[57:23] SPEAKER_00: forever for as long as you're overweight,
[57:25] SPEAKER_00: right?
[57:26] SPEAKER_00: So that's one.
[57:28] And the second thing is we all worry about side effects and
[57:32] that when medicines are
[57:33] SPEAKER_00: newer or whatever,
[57:34] SPEAKER_00: you don't really know fully.
[57:36] But I also think I'm more of an optimist and I say,
[57:39] well,
[57:39] what about the side benefits?
[57:41] SPEAKER_00: I don't think we
[57:41] SPEAKER_00: Eric Topol erictopol
[58:06] Anti-cancer effect of these medications that remains to be seen
[58:11] and determined.
[58:12] SPEAKER_02: Yeah, I know you made a really critical point.
[58:14] There's a lot of weight loss independent effects that have been
[58:16] documented for
[58:17] SPEAKER_02: heart,
[58:18] SPEAKER_02: for liver,
[58:19] SPEAKER_02: for kidney,
[58:20] SPEAKER_02: even osteoarthritis.
[58:22] SPEAKER_02: So, you know, it doesn't have to be only for the weight loss benefit.
[58:25] SPEAKER_02: We'll see.
[58:27] SPEAKER_02: Last thing.
[58:28] Well,
[58:28] besides,
[58:29] there was one question to get back to before I asked you that.
[58:33] SPEAKER_02: Robin Lister Johnson said,
[58:35] SPEAKER_02: well,
[58:35] SPEAKER_02: if I have a higher risk or abnormal mammogram,
[58:40] SPEAKER_02: better to get an ultrasound or an MRI.
[58:43] SPEAKER_02: Which would you suggest?
[58:45] SPEAKER_00: I mean, I think that, I really think it's a case-by-case basis.
[58:49] SPEAKER_00: I think if you have an abnormal mammogram,
[58:52] SPEAKER_00: usually the first test,
[58:53] SPEAKER_00: the low-hanging fruit,
[58:54] SPEAKER_00: is to look in that area with an ultrasound.
[58:57] SPEAKER_00: And it does depend on the abnormality.
[59:00] SPEAKER_00: You know,
[59:01] SPEAKER_00: if we think we see a mass on the mammogram,
[59:04] SPEAKER_00: like a lump,
[59:05] those are almost always picked up on ultrasound and easy to
[59:09] biopsy that way.
[59:09] SPEAKER_00: That would be my next test.
[59:12] If it's calcifications on a mammogram,
[59:15] those are not so easily seen by an ultrasound.
[59:18] SPEAKER_00: And so it's really,
[59:19] SPEAKER_00: you know,
[59:20] SPEAKER_00: the algorithm has gotten complicated,
[59:22] SPEAKER_00: and that's what we as kind of breast specialists try and figure out on an
[59:26] SPEAKER_00: individualized basis.
[59:29] SPEAKER_00: Often people,
[59:30] SPEAKER_00: you know,
[59:31] SPEAKER_00: if they have a mammogram and then they have an ultrasound,
[59:33] SPEAKER_00: it's a cancer,
[59:34] will do an MRI after that to make sure there's nothing else in
[59:38] that breast or the
[59:39] SPEAKER_00: other breast to guide treatment.
[59:42] SPEAKER_02: Okay.
[59:43] Now,
[59:44] the immune system,
[59:45] as you know,
[59:46] is not something we can check in the clinic.
[59:50] SPEAKER_02: We talked about genetics,
[59:52] SPEAKER_02: but we don't have a blood test or any test that says,
[59:56] SPEAKER_02: well,
[59:56] SPEAKER_02: your immune system is perfectly competent.
[1:00:01] SPEAKER_02: Protection is reduced.
[1:00:03] SPEAKER_02: And obviously, there's an immune system interaction with the risk of
[1:00:08] SPEAKER_02: And we just saw, for example, AI of the thymus.
[1:00:11] SPEAKER_02: Even people 80 years old, we thought the thymus was involuted.
[1:00:15] SPEAKER_02: Actually, it was perfectly, the AI shows it's perfectly functional, 100%.
[1:00:19] SPEAKER_02: Amazing.
[1:00:20] SPEAKER_02: Immune system clocks.
[1:00:23] So I'm hoping that we'll get smarter in the future because the
[1:00:27] people who have
[1:00:28] SPEAKER_02: intact immune systems probably are going to be a whole lot less risk.
[1:00:32] SPEAKER_02: of getting cancer of any kind, no less breast cancer.
[1:00:35] So I'm hoping to see further ways to help differentiate the
[1:00:40] risk of women who will
[1:00:43] SPEAKER_02: potentially change.
[1:00:45] SPEAKER_02: Right now we have so much as,
[1:00:48] even though you just mentioned we do things on an individual
[1:00:51] basis like the MRI or
[1:00:52] SPEAKER_02: the
[1:00:52] SPEAKER_02: The whole idea of,
[1:00:54] SPEAKER_02: you know,
[1:00:55] SPEAKER_02: everybody's showing up for a mammogram,
[1:00:57] SPEAKER_02: that's,
[1:00:57] SPEAKER_02: you know,
[1:00:58] SPEAKER_02: kind of treating it all,
[1:00:59] SPEAKER_02: everyone the same.
[1:01:00] SPEAKER_00: Agreed.
[1:01:00] SPEAKER_00: And I do agree in, like, customized risk.
[1:01:03] SPEAKER_00: I just think, you know, unfortunately, we're doing that work.
[1:01:06] SPEAKER_00: We're not, you know, we're just not there yet.
[1:01:09] SPEAKER_00: Like,
[1:01:10] SPEAKER_00: it's so hard to say on the one hand,
[1:01:13] SPEAKER_00: 90% of women who get breast cancer have no underlying risk factors that
[1:01:19] SPEAKER_00: And so how do you personalize risk?
[1:01:21] SPEAKER_00: Everyone's at risk, you know?
[1:01:23] SPEAKER_00: And so how do you pull back from those people until they develop,
[1:01:27] SPEAKER_00: like,
[1:01:28] SPEAKER_00: to your point,
[1:01:29] SPEAKER_00: the SNPs,
[1:01:30] SPEAKER_00: this and that,
[1:01:30] which really help people dig down in their risk of whatever
[1:01:33] disease it is.
[1:01:36] SPEAKER_00: You know, we're stuck doing what we're doing.
[1:01:39] SPEAKER_02: Right.
[1:01:40] SPEAKER_02: Yeah.
[1:01:40] SPEAKER_02: No, someday we're going to be smarter to find the 12.
[1:01:43] SPEAKER_00: Couldn't agree more.
[1:01:45] SPEAKER_02: who are really lifetime risk and the 88% who nothing to worry about.
[1:01:50] SPEAKER_02: Now, this book is a great service to the community.
[1:01:53] SPEAKER_02: Thank you.
[1:01:55] SPEAKER_02: You did a lot of work here,
[1:01:57] SPEAKER_02: years of effort to put together the best information,
[1:02:00] SPEAKER_02: the best best advice.
[1:02:02] SPEAKER_02: So thank you so much, Elisa.
[1:02:05] you're really you know besides all the great work you do at
[1:02:08] Mount Sinai and your
[1:02:09] surgery for breast cancer you've done a great thing here for
[1:02:14] putting this book
[1:02:15] together so really appreciate your coming on board Ground
[1:02:18] Truths today and for all
[1:02:20] the folks about 450 who joined us thank you for joining sorry
[1:02:24] we didn't get to all
[1:02:25] the questions there was so much to talk about I'm happy to come
[1:02:28] back because you're
[1:02:29] SPEAKER_00: a gem and
[1:02:30] And thank you for everything you do to get the right
[1:02:34] information out there.
[1:02:35] You are truly like my role model in all of this stuff and
[1:02:38] disseminating the best
[1:02:39] SPEAKER_00: information to your audience.
[1:02:42] SPEAKER_00: I'm so appreciative of the opportunity.
[1:02:44] SPEAKER_02: Oh, you're kind, Alisa.
[1:02:46] SPEAKER_02: I really appreciate it because that's what we try to do here is
[1:02:49] called Ground Truths so we get some good stuff out there for
[1:02:52] folks and that's why
[1:02:53] some people join and so many people go on when we post this in
[1:02:58] the days ahead so
[1:02:59] keep up the great stuff thank you I hope that a lot of people
[1:03:04] are getting on to the
[1:03:06] best best advice yes please pre-order the book it'll be out in
[1:03:11] a week thank you
[1:03:12] great to have you thank you so much Eric thank you for joining
[1:03:16] bye bye now

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