PODCAST: What to Know Before Your First (or Twentieth!) Mammogram

ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

KIM RIVERA HUSTON-WEBER: Hi, I’m Kim Rivera Huston-Weber and I’m a writer with Houston Methodist.

ZACH: And, Kim, what do you know about mammograms?

KIM: Well…

ZACH: I assume you know more than me.

[Laughter]

KIM: Yes, I do probably know more than you just because I turned 40 last year, and so --

ZACH: Congratulations.

KIM: Thank you so much. So, in continuing my unofficial series of episodes about things that happen to you when you become a middle-aged woman. I decided to do an episode about mammogram just because my friends and I were all aging into getting our first screening mammograms, and it struck me that so many of them had different knowledge bases about getting a mammogram. We all knew that we had to get one, but I think some of us were less prepared. And even for having written about healthcare topics for the pa -- Over ten years, I surprised myself, how I wasn’t prepared.

ZACH: So, obviously, I know what mammograms are, but as far as when you should start getting them, how often you should take them, blank slate for me. Now, as a man, I think it’s important for us to know as man like what this is all about as well. Because you don’t want it to -- ‘Cause there are so many of these health topics, right? You say, “Well, that’s, you know, that’s women’s stuff.” And -- but we all have women in our lives, right? And it’s good to know what they’re going through, right? When they’re, like, gonna go to a mammogram appointment, like, I don’t know. I feel, anyway, that’s it’s important for you to know what these women in your life are going through.

KIM: Yeah. And I think it might help to contextualize some of the fear and emotions that can come up, because, you know, you turn 40, you get the test. And I think this is how I surprised myself. It’s like I knew I had to go, and I knew that things were probably going to be fine. That you’re still going to get this cancer screening and, “Am I okay?” Like, when you get a callback, like, how bad is that. And I feel like even if you have the knowledge base about the test, you can still surprise yourself with how you feel about it. So, I think for the partners, for the folks that wanna support a mom, a sister, an aunt, you know, it’s important to know that it’s nerve-racking so, you know, kinda maybe go easy.

ZACH: Yeah. Even I remembered my mom getting mammograms and, like, they would give her a callback. And, like, oh, oh, oh, like, I’m like, “Oh, what does that mean?” But, you know, as we’ll talk about, everybody gets a callback on some -- to some degree, right?

KIM: Yeah. Yeah. Yeah. I mean, it’s not uncommon especially after your very first one. And, you know, I think that’s what really prompted me to focus on what you can expect during a mammogram. Since, you know, if all you know is you have to get one, I think it’s nice to know kind of what that appointment’s going to be like. You might not be able to get rid of that anxiety, but you might be able to feel a little bit more prepared.

ZACH: Yes. So, that’s what we’re talking about today. Mammograms, what are they, what to expect from appointments. And who did we talk to about this, Kim?

KIM: We talked to Dr. Ainel Sewell. She’s a Breast Imaging Radiologist with Houston Methodist.

[Sound effect plays to signal beginning of interview]

Thank you so much for being with us today, Dr. Sewell.

DR. AINEL SEWELL: Thank you so much for having me.

KIM: So, I’d love to start our conversation running through the basics of mammogram to get a -- who, what, when, where, why, kind of understanding with it. So, what is a mammogram and why is it the gold standard of care for finding breast cancer?

DR. SEWELL: So, a mammogram is essentially an X-ray. But it’s different from an X-ray that you would have for a body part, like your chest, or your arm, in the sense that it’s an extremely high-resolution X-ray. And it is the gold standard for detecting breast cancer because mammograms have been proven to be able to detect small breast cancers when they start early. When we’re looking at a mammogram, we’re not just looking at -- for mases in the breast. We’re looking for masses, calcifications, distortion, all of those. And by far and away, the mammogram is the gold standard.

KIM: So, who is a mammogram for? So, what are those recommendations for when someone should start having mammograms?

DR. SEWELL: We recommend that women who are asymptomatic and average risk start mammograms at the age of 40 every single year up until good health. I know that there has been some controversy regarding when and at what frequency should we do mammograms with the U.S. Preventative Task Force, they have changed the recommendation multiple times. But we here recommend, and as well as all of my peers through the Society of Breast Imaging, the American College of Radiology, and the American College of Obstetrics and Gynecology all recommend starting at the age of 40. We have continued with the same recommendations since the beginning. Start at the age of 40 every year until good health. And what do -- Sometimes I get questions. What does that mean, good health? And the way that I explain is with personal example. So, my mother was diagnosed with Alzheimer’s at age 52. I knew that her days we -- you know, it was years, were numbered.

KIM: Mm-hmm.

DR. SEWELL: Right. When she was diagnosed at age 52, we decided that’s it. We are no longer doing screening. We’re not gonna screen a colonoscopy. We’re not doing screening mammograms. Because we knew that her years were numbered, and it was. She basically -- she passed away at 62, almost exactly ten years after her diagnosis. So, that’s what that means up until good health. You know, she di -- was not in good health. I would no longer continue screening mammograms on her. What’s the point? But if someone, like, for example, Betty White. Betty White lived till, like, you know, wh -- how old was she?

KIM: Oh, I think she was in her late 90s.

DR. SEWELL: Yeah. She -- So, to say -- to say something to, like, Betty White, “Hey, Betty White, why don’t you stop screening mammograms at 74?” That would be absolutely foolish, right? Think about how many more years she had, right, of living and quality living. That’s the beauty of it, right? She was living her best life. So, that’s what I mean, “Up until good health.”

KIM: And what would be the scenario that someone would start younger?

DR. SEWELL: There are various scenarios for when a woman would start younger. One -- The first  and common one is when their mother has been diagnosed with premenopausal breast cancer. So, we usually recommend that a woman start mammogram ten years before the age of diagnosis of their mother. So, if their mother was diagnosed at the age of 40 which has happened, then technically, they would start at the age of 30. But they would not start below the age of 25. So, 25 is really kind of when we should, you know, there is no lower than that. We also recommend earlier screening for people who have certain types of genetic mutations. The first that comes to my mind is BRCA and that’s been kind of in the news. But there are so many more genes that every single year keep coming out, that’s also related to breast cancer. So, now, we have a slew of genetic mutations.

KIM: Got it. And so, is it someone knows that they have that genetic mutation, and they can work with their doctor?

DR. SEWELL: A lot of times a PCP or if a woman is seeing their OBGYN, they will kind of ask them their family history. And sometimes their family history would lend them to say, “Hey, you kinda maybe need some genetic testing.” And now a days, it is so easy to get a genetic test. They have some that are online that are just like 99 bucks. It’s as easy as just swabbing your mouth and sending it in and figuring out if you have genetic mutations. So, I think more and more, people are becoming aware that there are these tools available out there in case there is a question if there is a genetic mutation.

KIM: And thinking about mammogram, we’re thinking of generally that screening mammogram that you’re gonna get when you turn 40. Are there differences in types of mammograms? ‘Cause I know that there is screening, there is diagnostic. What are the differences there?

DR. SEWELL: So, the difference between a screening and diagnostic is actually they’re the same mammogram. One is screening for asymptomatic women starting at the age of 40. And then diagnostic means that there is a problem, just an issue. And it could be any kind of issue, whether it’s a lump, a dimpling in the skin, a rash on the skin, unexplained swelling, lumps in the armpit. So, there is a -- nipple discharge. There’s just a problem. So, it’s not that it’s a different machine or something between screening and diagnostic, but rather it’s just a different end goal.

KIM: In addition to detecting cancer, you also kind of touched on some other things. So, what other conditions or scenarios, what can you find that it’s not cancer but it’s a benign condition? What things can you find with mammogram?

DR. SEWELL: I mean, the first thing that comes to my mind is we have diagnosed a significant amount of lymphoma. And the reason -- on screening mammogram. And the reason is because when we do screening mammograms, there are four different views that we get on the oblique, the mediolateral oblique views. We actually take a very good look at the lymph nodes in the arm pit. And in that way, we have seen large lymph nodes that then have prompted biopsies which then come to find out it’s lymphoma. So, that definitely not breast cancer but a condition that someone would want to know. The other thing that mammograms are also -- There’s a lot of research going into this, is there are -- We can see on mammograms ‘cause it’s extremely high-resolution exam. You can see vessels. You can see pores, you know. You can see just this am -- a great amount of detail. And one of the things that we can see are vascular calcifications. And some of us put that in our report when the patient’s age doesn’t match what we should be seeing for vascular calcifications. And that’s actually indicative of that there might be a cardiovascular issue happening, and we kind bring it to light. Like, you know, the degree of vascular calcifications is disproportionate to the patient’s stated age. A lot of times, maybe, you know, the patient has some kind of underlying medical condition such as diabetes. But sometimes they don’t know. And, you know, I’ll tell you that one of the major, you know, things that threatens women’s lives besides breast cancer is cardiovascular disease.

KIM: Yeah. That’s so interesting. I wouldn’t think that you could detect heart disease on a mammogram.

DR. SEWELL: Mm-hm. Mm-hm.

KIM: And so, let’s kind of shift to talk about that experience of getting a mammogram and what women can realistically expect from the test. So, I think we all know that women lead exceptionally busy lives, whether they’re taking care of families, aging parents, have a career, you name it. So, what kind of time commitment is it to get a mammogram?

DR. SEWELL: I mean, I completely -- as a woman who has three children myself, and married to another physician, I completely relate. Sometimes I will shock myself when I realize, “Wait, I haven’t gone to get a Pap smear.” Or, I haven’t seen my OBGYN in like a really long time, and I’m like, “Oh, my God.” I mean, that’s just unbelievable. Like, and how -- like, “I felt like that was just yesterday. Is it really three years?” And they’re like, “Yeah.” And I’m like, “Oh, Lord.” So, I completely understand that, you know, more than anyone that yes, you live busy lives. So, in those sen -- in those scenarios, I always recommend that I think that sometimes there is things that are connected to us. Like, there are memories with some emotion. So, I always tell patients the best to always remember that you are due for your mammogram is to associate the date that you get it with something that’s important to you. It could be your birthday. It could be your anniversary. It could be when your children were born on a certain day. That’s a great way ‘cause -- and then, that day passes and you’re like, “Wait a second, I didn’t get it.” But the time commitment, I mean, it’s very easy. We can -- we -- you know, we can -- patients can register online, make their appointment online. And once they come in, they’re taken to the back, and it’s just four simple images. I’ll tell you that it’s a lot easier an exam that other types of screening exams. For example, colonoscopies, which I just got done doing. And I can tell you, I would prefer a mammogram over a colonoscopy any day of the week. In fact, I will -- I myself was a little bit scared about that, the prep and all of that. And then just leading up to it, you know, the fact that you get sedation, it’s more invasive. I was telling a bunch of people like, “Which one would you prefer?” They’re like, “Oh yeah, I would take the mammogram any day of the week.”

KIM: I think that kind of leads into this next natural question. Is there any prep that you have to do before your mammogram?

DR. SEWELL: No, we don’t have to do any kind of prep before a mammogram. Like, literally anyone can have it done. The only thing that we advise women is you should go probably go in with a -- with a kind of an outfit where you can take off the top and then have, like, either a shorts or pants on the bottom. I think that would be better so that you’re not completely naked. But we’ve had women naked and no worries. We just put them in a robe. And then, kind of just make sure that, you know, the skin is nice and clean. Don’t apply any kind of fragrance. Don’t apply any kind of creams. Some of those creams actually have aluminum in it which can actually show up on the mammogram, the aluminum in creams. So, just clean, dry skin and that’s about it. And I think the only thing that I would say is just, you know, it’s kind of just getting to that point, scheduling it, going through the motions of getting to that point.

KIM: So, I think some women maybe accustomed to scheduling an appointment with their gynecologist or OBYGN around their cycle, is that something that you should take account of when scheduling a mammogram?

DR. SEWELL: No, actually, it doesn’t really matter when you are in your cycle when you schedule the mammogram at all. The only thing I will say is if you know that your breasts feel more sensitive during a certain time of the month in relationship to your cycle, then you probably shouldn’t have the mammogram a the point in time, only because you tend to be more sensitive. Alternatively, you could also take some Aspirin and call it a day.

KIM: So, could you broadly explain what a woman will experience during a mammogram? So, kind of walk me through what someone can expect from that time that their name is called in the waiting room and they’re taken back.

DR. SEWELL: Yeah, absolutely. So, we -- once your name is called and you’re taken back, our mammo techs will hand a woman an iPad. And in that iPad, you -- sometimes they can do it there or they can do it before they arrive to the appointment. It’s just a kind of a series of questionnaires, you know. “Have you ever kind of had any kind of breast surgery?” And whether it’s breast augmentation, or a reduction mammoplasty, or just anything done, you know, any type of surgical procedure. “Have you ever been diagnosed with breast cancer?” And then, kind of they also will take some of your -- also family history. “Is there anything -- you know, is your mother, or father, brother, or sister, your own child diagnosed with breast cancer?” So, after that questionnaire is filled out then our mammo techs will take the patient to the back, get them changed, provide them with a robe. Give them privacy to change. And they will also instruct them, kind of, you know, “If you have any deodorant or any creams on you, you know, here’s a little wipe to kind of wipe it off.” And then, the mammo tech will basically position you. And the most discomfort that a mammogram is is just the compression. And that’s -- So, and the topic that I actually want definitely to cover. Compression in a mammogram is so incredibly important for so many various reasons. Number one, it produces a better exam. We need that compression in order to differentiate, is there something there, like, a mass, or is it just tissue? And what it does, it kind of spreads out the tissue during that mammogram so that we can get a good look. If a mammogram ever feels, like, not super, super tight, it’s probably not the best mammogram. It should feel tight. A lot of times the patients think, “This tech is trying to squeeze me to hurt me.” No. We’re not trying to squeeze you to hurt you. We’re just trying to -- we’re trying to give you the best possible exam and we know that that compression is so important. Not only does it produce a better mammogram, but it also decreases the amount of radiation exposure that the patient’s gonna have. So, for all reasons, it’s just -- It’s incredibly important. But other than just taking four images with it and the mammo tech will walk you through it, and a little tight squeeze that lasts for a couple for of seconds, that’s pretty much it.

KIM: In thinking about having a test and kind of the fear that can kinda come along with it, there is just no lack of stories online that kind of sound a little harrowing where people are describing their pain from, you know, someone just being like, “It’s -- It was mild discomfort.” You know, just real brief mild discomfort to someone saying that, you know, they felt bruised, or they had skin tearing after. So, is there anything about our breast type that can affect that pain that we may experience during a mammogram, or it is ju -- does it just come down to, you know, what our personal pain levels are?

DR. SEWELL: Yeah, I think -- I think it actually just comes down to that. Everyone is so different. Everyone is so unique. Some people have no -- They don’t feel anything. You can squeeze them, you know, and it’s just like they don’t feel anything. And then some women, you barely any squeezing and it just -- it really hurts. So -- And those women, I do always advise them like, “Hey, you know, make sure you’re coming at the right time if you still have your menstrual cycle. And on top of that, just go ahead and take some Aspirin if it’s gonna make you feel better, and it’s gonna be more tolerable.” Also, we get certain kind of questions regarding women who have breast implants. We see tons of women here who have breast implants. You know, they -- the question is, “Oh, is it  -- the mammogram gonna rupture my implants?” I have never seen a mammogram actually rupture  implants. It’s a little bit more discomfort because they -- what they do is they push the implant back and then try to capture the tissue that’s in front of it. But I’ve never seen a mammogram rupture an implant.

KIM: Yeah. That poses an interesting question. So, you kind of described how the tech will move it. Are there any other considerations that -- for women that have had breast implants that they need to know before going into a mammogram?

DR. SEWELL: I mean, it’s just that they’re gonna have to have more exposures because they’re gonna have -- not only do they have the four standard views with the implant in place then they have the views with the implant displaced as much as possible. So, that’s gonna equate to more radiation. But a radiation from a mammogram is negligible. And, you know, I cannot emphasize this enough. There is radiation all around us, all around us. You just don’t know it, but it’s there. There is radiation when you fly in a plane. There is radiation when you go to a high altitude. There is just radiation from equipment, and computers, and everything. So, I don’t think people realize that ‘cause it’s -- They don’t see it. But then, they think that the radiation from a mammogram is going to harm them in any which way and that’s just not true at all.

KIM: You had mentioned that it is okay to take a pain reliever before your mammogram if you know you’re particularly sensitive or if you kind of have a lower pain tolerance. For those who might be concerned about tearing -- is -- you’d already previously mentioned that we really shouldn’t be using creams. So, would that be a no go on using like a lotion or something trying to…

DR. SEWELL: Yeah. Yeah. We usually -- we usually advice against any kind of creams or lotions on the breast at the time of the mammogram. And although skin tearing can happen, I will tell you that actually since I’ve been here at this particular Breast Center, I -- we rarely, rarely -- I think I’ve seen one case in the past eight years since I’ve been here. And so, I don’t -- I don’t think that’s a very common thing.

KIM: And that’s good for people to hear that. You know, there’s just no shortage of horror stories and, you know -- Well, my friend, of a friend, of a friend, had tearing. And, you know, you know how those stories can spread.

[Laughter]

So, I kinda like to talk about results and kind of what happens after a mammogram. So, how long does it usually take for women to get results and, you know, or do you have any tips for how someone can read their results?

DR. SEWELL: Yeah, absolutely. I think here at Houston Methodist, because we have our electronic medical record, which is connected to MyChart, every mammogram that is done today usually will get read today or tomorrow. We actually read it very quickly. And as soon as that is read, I would say 20 minutes, there is usually a notification on -- if you’re signed up for MyChart which we recommend that everyone be signed up. There’s a notification that pops up on your phone saying, “Hey, you got results.” So, it’s that instant. And patients can pull up their actual report on the app and see what it says. But that’s how quickly they got their results. Yes.

[Music to signal a brief interjection in the interview]

ZACH: As Dr. Sewell mentioned, half of women aged 40 and older are found to have dense breast tissue. Breast density is often inherited. So, talking with female relatives may give insight to whether you have dense breast tissue. Lower body mass index and the use of hormone therapy for menopause is associated with denser tissue and having children and getting older can lead to having lower breast density. Breast density falls into one of four categories. About 10% of women are in the entirely fatty breast tissue category where the breasts are almost all fatty tissue. Scattered fibroglandular breast tissue occurs in about 40% of women. In this type, someone has mostly fatty tissue but there are some areas of dense glandular and fibrous connective tissue. In heterogeneously dense breast tissue, there are many areas of dense glandular and fibrous connective tissue and some fatty tissues. This type is found in about 40% of women. And finally, extremely dense breast tissue is when the breasts are almost entirely comprised of glandular and fibrous connective tissue. This type happens in about 10% of women. If your mammogram report calls out that you have dense breasts, it means that you fall into either the heterogeneously dense breast tissue or extremely dense breast tissue categories. Having dense breast tissue is normal but you will need to work with your doctor to follow a screening schedule that’s right for you.

[Music plays to signal resumption of interview]

 

KIM: After the break, we talk to Dr. Sewell about how to manage anxiety and what you can expect with a callback.

[Music]

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KIM: How common is it to get a callback after your very first mammogram?

DR. SEWELL: Yeah. So, callback refers to also being recalled. It also goes by that name after a mammogram. Which means we just need additional images or something in order to clarify what we’re seeing. And there is no reason to get anx -- be anxious about that. But let me back up and just say, the one very interesting thing about a mammogram is a mammogram is a fingerprint of you, you’re -- like, every single women is so incredibly unique that your breast tissue looks different from someone else. Even in your same family, your breast tissue can look vastly different. One of the issues that happens after a first mammogram, which is your baseline, is we don’t know what’s normal. Some women have breasts that are complete symmetric, you know, from one side to the other. It looks like two hands coming together are just perfectly symmetric. In some women, I say the majority of women, do not. They have tissue kind of -- There’s like a little patch over here. There’s like, it’s missing over there. And that com -- Again, that’s completely normal as well because we have so much uniqueness to us. So, sometimes we just kinda wanna clarify and just make sure, “Hey, that’s normal tissue and nothing to be concerned about.” Because on mammograms, you know, as much as everyone would think that on a mammogram, you know, a cancer is just waving you down and saying hello to you. And, like, has, like, a red flag waving in the air, “Hello, I’m cancer.” That’s not true. Breast cancer can look like normal tissue, and normal tissue can look like breast cancer. So, it’s very hard to differentiate that. So, that’s -- It’s very common to get a -- to get called back from your first mammogram for that exact reason we don’t have your fingerprint. When after the fingerprint is established, then when the next mammogram happens then we already know, okay, well, that’s normal. That’s normal for this person, you know, and so on, and so forth. And the power of mammography really comes in from doing that same exam year, after year, after year. That’s when we are gonna pick up the smallest little thing on the mammogram. But if somebody, you know, doesn’t and comes in maybe once every ten years, or -- how -- and bounces around to different breast centers, then nobody knows your fingerprint. Does that make sense?

KIM: Yeah. Yeah. That’s interesting. So, kind of to your last point there. Does it matter where you go for your mammogram?

DR. SEWELL: Well, I think that you have to be in a place that is fully committed to updating and keeping their equipment to be the best possible available at the current time. You need a radiologist who knows what they’re doing. Those radiologists tend to be fellowship trained and they tend to be very specific to that one field. So, I -- All I do ever since I graduated in 2014 is 100% breast imaging to the point where if somebody shows me a brain MRI, I’m like, “Ah, let me take a look, but I’m gonna call my buddies over there at neuro,” because I don’t feel comfortable any more looking at the brain MRI. Same thing with a bone X-ray. So, I’ve become, you know, so specialized that, you know, you tend to pick up just the slightest things. So, the equipment, who reads it and, you know, and a radiologist who kind of oversees that kind of quality and maintains that quality.

KIM: Yeah. And having trust in the center that it’s a good place to go, should you be going to the same spot every year for your mammogram, or can you jump around like, “Oh, this one place is near my office.” Or, “This one is near my house.” Can people jump around like that?

DR. SEWELL: Yeah. That’s a great question and a great point. I highly recommend to not bounce around. Because again, from that uniqueness perspective, you know, your breasts are so unique to you. Having, you know, prior is so important for the ability for that radiologist to pick up, detect a change. You need to have those priors. If someone is to bounce around all over the place, I always recommend that you ask for that facility to burn your prior images onto a CD and then take it with you. In doing so, when you get to the next place, you can, you know, submit those and then they will have them. They’ll upload them. Well, we constantly are fighting that battle, constantly. We have patients who hop around to different places and then we have to go hunting for these prior mammograms. And sometimes these other places are not as forthcoming with them. You know, they’re short-staffed, you know, they’re busy. And they will get to it when they get to it. So, you know, it could take some time. And when -- then these women get super anxious waiting for their results, right?

KIM: Well, because it can be a nerve-racking thing.

DR. SEWELL: Oh, yeah.

KIM: And kinda to that point, you get a callback, is scheduling that next mammogram and any of the additional tests that may come with it, is that like considered, you know, a quote unquote, ”emergency”? Or should you be trying to get in as fast as you possibly can?

DR. SEWELL: That’s a great question as well. And one thing that we do here specifically in our Breast Center is our techs will get a li -- like I said, when a mammogram is done, it is read either the same day or the next day. And the next business day our techs are pulling that list to see who was called back per say. And they will actually, usually, beat the patient to the punch. So, we’re usually calling the patients and they have no idea. And they’re like, “Hey, what? What happened?” And I think that the reason we do that is because, you know, it is very anxiety provoking when somebody tells you, “Hey, there’s something that needs to be clarified.” You know, I can’t imagine anyone in the world who’s gonna think that that’s, you know, not anxiety provoking. So, we do that so that the patient knows, “Hey, we know that you’re being called back. You know, and we’re here where I’m calling you to schedule.” So, that kind of everything is laid out there. And on top of that, if there is more information on the report, that my techs are instructed to give the patient. For example, I always like to put kind of what I’m thinking on my report. If I say there is, you know -- There is some masses, some round and oval masses everywhere. I will actually say, “Findings likely represent fibrocystic changes.” My tech knows when they’re calling that person they’re saying, “Hey, I -- She thought there were a bunch of cysts in your breast. We just wanna make sure that that’s what it is.” And then that kinda gets that little bit of like, “Oh, okay. Alright. Okay, that’s cool. That’s not bad.” You know. But we do that process of making sure that we call the patient right away. And it is to kind of, again, ease that anxiety and make sure that they already know that there’s a plan in place for them, that they didn’t get lost. And with that said, we also run audits, you know. Every single week we run an audit. “Did somebody fall through the cracks? Is there anything missing?” You know, just to make sure again that nobody falls through the crack, everyone is accounted for.

KIM: Could you describe what usually happens when someone comes back for that additional imaging?

DR. SEWELL: Absolutely. So, it depends on what was found during the mammogram. If I think I’m looking at whole bunch of cysts everywhere, sometimes I don’t need to have additional radiation exposure. I don’t need an additional mammogram for that patient. I just kinda wanna go straight to ultrasound, and then ultrasound will help us. So, all these other types of exams that are added, like, are dar -- part of our armamentarium for diagnostics, and it includes ultrasound. It includes MRI. It includes biopsies. These are diagnostic tools to help us. But far and away, you know, it is really the mammogram that is gonna be the king and the queen and is gonna kind of tell us how concerned we should be. Sometimes we do need ultrasound to kind of penetrate especially dense tissue and be able to look at something and see, is it cystic inside or is it solid inside. And so, sometimes it depends. We can go straight to ultrasound or in other circumstances we need further images to kind of tell us what’s going on. And then, in those circumstances we gonna get a mammogram first and then possibly an ultrasound, or just the mammogram and just stop right there. Again, it all depends on what we’re looking at.

KIM: Got it. And so, kind of with that, how common is it to discover that it’s dense breast tissue or it’s cysts, or what are some of these other benign conditions that you might see?

DR. SEWELL: There are a ton of benign conditions that I couldn’t possibly go into in the time span of this podcast. I mean, that’s just so -- That’s the most amazing thing about breasts. There is so much benign stuff. And we have to kind of, like, tease it out. And to take one topic at a time, so, dense tissue. 50% of women are going to be dense. So, if you are dense, you are in good company. 50% of the population you are not abnormal. You are normal. You just have dense tissue. And the way that I like to describe dense tissue is, let’s think of your dense tissue as snow. So, you have snow in your breast. And one of the findings that I’m looking for, let’s say, breast cancer is a snow bunny. You could imagine if I’m looking out on a plain field of snow, pure white snow, and I’m looking for a snow bunny, it is very hard to decipher where that bunny is unless it moves or, you know, does something. So, it kinda, like, blends into the background. So, somebody who has dense tissue, it makes it just that much harder to see. If you were to have not dense tissue and you were to have -- you’d be part of the other categories. It’s easier to spot that snow bunny. It’s like finding a snow bunny on a black basketball concrete court. You know, it stands out. But that’s not the only thing that we look for when we’re looking at mammograms. We’re looking at, you know, snow bunnies. We’re looking at calcifications which we can see in the densest of tissue. We’re looking at distortion as well which looks, like, almost like a cobweb. So, there’s other things that we’re looking at when we are looking for, you know, those particular things. But, yes, benign conditions in the breast -- just a galore of benign conditions, benign mases, cysts, all kinds of things.

KIM: Once you have that baseline and you know what your fingerprint is, how would that inform how someone moves forward with their mammogram regimen?

DR. SEWELL: Yeah. That’s a great question. So, if you were to be part of that group which is again, just represents 50% of women and you find out that you have dense tissue. I think, again, you have to understand, number one, you’re normal, you know. Number two, you know, it could be a little bit more difficult to interpret your mammogram. So, I think, with that in mind, you kinda have to make a decision if -- let’s say if that person has dense tissue and they were to tell me that someone in their family, especially a first degree relative, a mother, a sister, or two maternal aunts, their dad, something like that, like, they have a history of cancer. Well then, they might want to get their mammogram and get a screening ultrasound at the exact same time. And, actually, in certain countries where dense tissue is very, very, very common which are Asian countries. So, anywhere in Asia, those women have the densest tissue of all. They usually get screening mammograms with ultrasounds for every single time that they get it because they are known to have extremely dense tissue. So, you can proceed with getting your mammogram and getting an ultrasound. Dense tissue is just an interesting topic because I think more and more, it’s becoming recognized as its own independent risk factor for it to develop breast cancer. You know, I don’t know how strong that is but it’s -- I know that research is kind of going that way. So, that’s something that you could do. Some patients, you know, it depends on a lot of different factors. They might wanna have a screening mammogram with an MRI for example. And, you know, if they’re considered enough, they have enough lifetime, you know, risk of 20% or greater that they would want to pursue that one.

KIM: You go in, you have the second mammogram. Can you discuss what the next steps could potentially be after that diagnostic mammogram? ‘Cause it sounds like you could find out you have the dense tissue, something benign. But let’s say it’s not one of those things. What do those next steps look like?

DR. SEWELL: Yeah, absolutely. So, every single diagnostic patient, if there is something that they were recalled for, the radiologist here, whether it’s me or one of my other colleagues. We talk to every single patient. So, every patient will get to usually meet us. So, we take the time to meet with them and after their exams are done and let them know what the plan is. I love it when I come into the room and I’m like, “Hey, everything is great. You know, you got just a bunch of cysts.” And I kinda sometimes explain, you know, what is that because sometimes people don’t know. That’s just like little simple water balloons in their breasts and, you know, little bit of fluid. Nothing to worry about. Completely normal. But then, you know, sometimes we also have to kind of discuss next steps. Like, “Hey, I see something, you know.” And then, have that discussion because I always like patients do understand what’s coming up next. So, if I have to recommend the biopsy then I discuss the biopsy with the patient at the moment. Kinda describe, you know, what they will be going through when they come back for the biopsy. And then anything, any kind of barriers that we need to be aware of. Like, I’ve had patients tell me, “I don’t think I can handle the anxiety going through this.” “Well, okay. Well, let’s get -- let’s get a plan in place.” You know, and the plan maybe, you know the day of your biopsy before, but, you know, after you are consented. Patients have taken Ativan, you know when they’re here or, you know, Valium, something to kind of get that edge off and then we proceed with the biopsy. Anything that we wanna discuss we discuss after everything is said and done.

KIM: Got it. And so, you can kind of have a feeling that you -- It’s a safety thing, right? So, you kind of have a game plan for what’s going -- no one’s going to leave you hanging, more or less.

DR. SEWELL: Yeah. No, they don’t. They know usually -- And I think our referring clinicians here appreciate that.

DR. SEWELL: I’m not just gonna put it in some report that’s gonna appear in their chart and it’s gonna kind of blindside them. I wanna know -- them to know what’s coming, and what we gonna do, and how we’re gonna do that biopsy, ‘cause there’s different ways that we can do it.

KIM: Kind of to that point, I surprised myself with how emotionally unprepared I was for my mammogram. I’ve been writing about health care for over a decade, and specifically, focusing on women’s health topics. Even though I knew what to expect and I knew that to expect a callback, I could not stop my lizard brain from, like, clicking on and that anxiety coming up. My friends and I we’re all at that age where we’re all kind of in that cascade of getting them. And so, I think they were all unprepared in different ways. And so, really, that’s what prompted me to wanna do this episode. And so, I know it’s unrealistic to say, “Just don’t be anxious.” You know, everyone loves being told that, right? So, you’re not going to be able to prevent those feelings from bubbling up, but what advice could you give a woman to help ease that anxiety or that fear that comes up at any point, so whether it’s before, during, or after a mammogram?

DR. SEWELL: Yeah, I mean, absolutely. Everyone who works here knows that. And it is incredibly anxiety provoking, the whole experience, right? The idea of that there could be possibly something wrong with you. Every single person who works here, whether it be the people who check you in at the front desk, the patient -- the person who registers you, and our mamo technologists, our ultrasound technologists, our nurses, our, you know, our lead techs, every single person here knows that that person is anxious. And I will tell you that sometimes that anxiety can manifest in various ways. It can manifest as anger. It can manifest as, you know, like a little bit of attitude, you know. And we all kind of understand that, you know. I -- We understand that when someone comes in here and perhaps, you know, you know, they’re acting maybe a little bit bizarre, I always tell all of our staff here, “Listen, they’re anxious. Like, they’re -- It’s the anxiety that’s talking. It’s not that they’re,” -- I think that if I were to meet most of these women in, you know, some kind of function, I would meet them at a bar, or meet them at a club, or meet them at a dinner, they would be lovely, lovely, lovely, women. You know, we would get along fabulously well. But under these circumstances, you know, different personality aspects rear its hear.

KIM: Oh yeah. I tried to make my breast tech laugh.

[Laughter]

‘Cause, like, you know, you have your arm up and you don’t have any deodorant on. I was like, “Houston summer, am I right?”

DR. SEWELL: You know, exactly. Exactly. So, I mean, the best thing that I can say to ease that anxiety is we -- all of our staff is, you know, again, trained to understand that sometimes that’s gonna happen. And again, we do little things that I think have a huge impact to ease someone’s anxiety. For example, it’s read, you know, it’s read on the same day pretty much. You get your results instantly. Even people who are not tech savvy and don’t get their results via MyChart, they get sent a letter. You know, we always send a letter to give you those negative results in case, you know, there’s some people who just don’t wanna use an app or, well, you know, what have you not. We do a lot of other things like talk to our patients as soon as the diagnostic exams and all the exams are done for the day to kind of, you know, let them know. And there is really truly nothing I love more than to see that relief. And I can see it when I walk into the room like, “Hey, everything is fine.” I don’t even like, “I say that at the doorway. Like, I’m like going into the room saying, “Everything is fine.” Because as soon as I say that everything is fine, you can see it on their faces, “Oh, my God.” They, like, sighed this, like, huge, like, “Oh, my God. I was so scared. I was so scared.” I’m like, “Yeah, I know because everyone is.” Like, I don’t expect anyone to not be afraid, you know. And if you’re not, then you’re kind of a little bit weird.

[Laughing]

And we have run into some of those people. There are those people who are, like, completely unafraid of a biopsy and they’re just like, “Yeah, bring it.” I’m like, “What?”

[Laughter]

You know, because I personally don’t, you know, don’t want needles. I have a fear of needles as well. And we also, I would say, you know, take that into account, you know. If I don’t need to call someone back for something and I know it’s gonna be benign, I mean, I’m not gonna call that person back, you know. Because why am I gonna put them through that when I know that some things could be benign? Same thing with the biopsy, you know. I think we all -- I carry a lot of that weight. Like, I wanna make sure that when I recommend the biopsy, it is absolutely warranted and it’s absolutely necessary. Because I don’t want to just willy-nilly recommend those things. Because I do know that at the end of that needle is a patient who is very anxious about everything. The other thing that we specifically do here in the Breast Center is what’s called post-biopsy clinic. And I don’t know if you’ve heard of this, but when I got here and I’m -- I’ve already -- I’ve been here since 2016. It’s kind of hard to believe that. But when I got here in 2016, I noticed that women were getting their results for, like, biopsy results, in weird kind of ways. You know, a lot of times we -- They would tell them, “Okay, well go find your PCP who recommend the biopsy, and they’ll give you the results.” Or, “Call the office and then maybe you’ll talk to the nurse and maybe she’ll give it to you.” Sometimes those results would fall through the cracks, and we would then have angry people at our door saying, “I didn’t get my results from my PCP. I want them right now. Can you give them to me?” It presented so many different challenges. And what I saw in all of these women were that every single one of them was super anxious. And that anxiety started manifesting this anger because they wanted those results. So, when I became medical director, which happened pretty much shortly after I arrived here, my first -- my first line of order and business was to change that. And I said, “You know, I think that the best way to give these results is in person.

KIM: Mm-hm.

DR. SEWELL: You know, and our staff was, like, a little bit hesitant. Like, “Are you sure? This is gonna be very time-consuming, you know, blah, blah, blah.” But I said, “No, absolutely. The best person to give that patient the results is the person who performs the procedures.” And that is considered a best practice. So, since 2016 we’ve been doing that. What we do is we schedule -- every single biopsy we schedule an appointment. Sometimes if I think, like, you know, “Hey, it’s gonna be something benign. Nothing to worry about.” Or, you know, I’ll let the patient know we’ll sometimes call them to -- as soon as we get them. And I literally mean that. As soon as those biopsy results hit my hand, I’m calling. And especially if it’s a Friday, I wanna call them ‘cause I want them to take it easy that weekend. I don’t want them to stress out that whole weekend. I don’t want sleepless nights. I don’t want, you know, somebody, you know, just, you know, going through their mind, like, “What if, what if.” But if they are malignant results, which we usually have an inclination of when it’s gonna happen, we do bring them back in. And we bring them back in with our nurse navigator. And in conjunction with our nurse navigators, we basically help the patients get to the next steps. We sit down together and have open discussion about what the biopsy results show. And I can’t begin to tell you what a positive impact that’s had. Not only our referring physicians love that, our patients are -- every single person just loves that. Because when you say something like that to someone, “You have cancer,” most people aren’t gonna take it very well, right? Right away, their mind kinda goes towards very dark places. There’s a lot of fear. “Am I gonna -- Am I gonna be able to take care of my children? Am I gonna be able to take care of my spouse, you know? People depend on me.” Right? So, whenever you can give someone a result and phrase it in such a way, like, “Hey, I know these results aren’t what you want, but it’s cancer. And -- but guess what, it’s this tiny, tiny, little cancer. And guess what, your lymph nodes look completely normal.” And, you know, and a lot of times in those situations, people do not have to undergo the effects of chemotherapy. Which when we think of the word cancer, that’s usually what people are afraid of. People are afraid of chemotherapy, losing their hair, vomiting, becoming sickly, right?

KIM: Yeah.

DR. SEWELL: If you can tell someone that, I mean, what a huge difference. You can see, like, this -- just this weight lifted off them, like, “Oh, my God.” So, we did that with that in mind, you know. We’re dealing with anxious women. We want to make sure that they are given these results in a warm, supportive, environment, you know. So, that they can -- after they leave here, they have a plan in place. They know what they’re gonna -- what’s gonna be happening. Somone’s gonna get them an appointment. They know what the next steps are. And then on top of that, they are also given information on the way out. Like, an actual folder and it says, “Please stay away from certain websites.”

[Laughing]

KIM: Yeah. I -- you know, and I feel like that’s kind of why I wanted to have this conversation. Because I think when you are coming to that age, when you’re becoming 40, and you -- your doctor tells you, the internet’s telling you it’s time to get your mammogram, like, you might wanna look at certain websites and it’s really easy to go down kind of a rabbit hole. Well, thank you so much, Dr. Sewell. This has been a really good conversation. And I think something that I hope women can kind of ease their anxiety knowing what to expect for that first mammogram and then, you know, maybe that 75^th mammogram. Well, that person might be living into their hundreds, so maybe that’s --

[Laughing]

DR. SEWELL: Yes.

KIM: That’s not good there but…

DR. SEWELL: Yes, absolutely.

KIM: Just to live our best lives.

DR. SEWELL: Yeah, absolutely. Thank you so much for having me. I appreciate it.

KIM: Of course. Thank you so much.

[Sound effect plays to signal end of the interview]

ZACH: You know, Kim, a couple things off the top there in your conversation with Dr. Sewell is the idea of, like, good health, right? Continue to get mammograms up until you feel like you’re not in “good health,” quote and quote, anymore. And the thing that was interesting that it’s different for everybody, right? Like, she used the Betty White analogy which I think is a pretty good analogy, right?

KIM: Oh yeah. I really knew that I would start getting mammograms at 40, but, you know, I just thought I would just get one for every year of my life and, you know, until the inevitable end. But apparently, I -- and I understand why with the concept of good health it’s -- at a certain point, you’re not going to want to do anything about it. But as long as you’re living your best life, like, continue to get those screenings to make sure that you’re in tip-top shape.

ZACH: Yeah. ‘Cause there’s such a -- And you guys talked about this too. Like, they will say, “Well, it’s 40, but then maybe if you have a family history a little sooner.” Like, I have prostate cancer in my family, so I know, like, okay well, there’s a certain age for that. But, hey, if it runs in the family a little sooner. So, there’s always those exceptions, right? So, that’s a little -- that’s a little sliding scale. But then, like I said, on the other end of the scale, right, it’s like, well, that’s all really up to the own individual at that point. Although they do recommend getting regular screens. I’m not saying not to but --

KIM: Exactly. And, you know, she gave the example of her mom. And, you know, and I think about that with some of my other relatives. I feel like I’ve pushed some of my aunts to be like, “Hey, what are you doing? How is it going?” And then, you know, some of them aren’t in the best health. And I can understand how it might not be something that they wanna continue doing if they don’t have to.

ZACH: Yeah. It’s unfortunate that I think we just become more and more familiar with things we probably should be doing through, like tragedy, through crisis. Like, I know a lot about prostate cancer because it’s been in my family. And all the people who have had breast cancer in their family probably know a lot more about breast cancer than the average person, right? And then you get really educated about it and you realize, “Oh, wow. I should be doing this, this, and that.” And again, preventative care, right?

KIM: Of course. Of course. And then, another thing that struck me was just how prepared radiologists and all the staff are to help people that are feeling anxious. It really feels baked into every part of the process which is really nice. Even if you are a person who manages anxiety with -- Like, I tried to my breast radiologist laugh when I was in mine just --

ZACH: Knowing you, that makes a lot of sense. Yeah.

KIM: Yeah.

[Laughing]

Just because it’s -- it can be uncomfortable. It can be anxiety provoking. But I think everyone is really prepared for however that might present in a person, that anxiety. And I think that makes me feel a little bit more comforted just in case, you know, next year when I have to go in for my annual, and it happened -- I happened to get off the wrong side of the bed that day, they’re ready. They won’t care.

[Laughing]

ZACH: Yeah. I mean, Dr. Sewell talks about this too. Like, a lot of people respond to this -- the stress of this differently. And some people don’t respond at all to it. And she’s like, “Hey, this is,” -- Maybe you should respond a little bit more.

[Laughter]

That was an interesting comment she made.

KIM: Yeah.

ZACH: But everybody processes this stuff differently, right?

KIM: Yeah.

ZACH: So, and that makes sense.

KIM: Yeah. I thought Dr. Sewell did a very great job of explaining what you can expect at every point with getting a mammogram. And, you know, I think that’s really important for people to feel both, one, engaged in even making the appointment. I think if you are able to know what is going to happen during an appointment and also understand, maybe it might be a little bit stressful, but everything is designed to help you through that. I think it’s going to help people be able to make a mammogram with confidence. Especially if, you know, that 40^th birthday comes up and you’re like, “Ugh, I’ve gotta do this thing.”

ZACH: Mm-hm.

KIM: And not have any fear around it.

ZACH: Yeah. And hopefully, this conversation brings people some comfort, some education about it, right? The unknown is always scary, so now, hopefully this has become a known.

KIM: Of course, you know, I think that’s really the hardest party of anything, right? Whether it’s -- It’s just about getting started. So, you know, make that appointment. Get it checked on. And you can only find out more about yourself, which is a good thing.

ZACH: Absolutely. All right. That’s gonna do it for this episode of On Health with Houston Methodist. We drop episodes Tuesday mornings, so be sure to share, like, and subscribe wherever you get your podcasts. And until next time, stay tuned, and stay healthy.