Clarifying the myths and facts of breast cancer

The Means Report

AUGUSTA, Ga. (WJBF) – The Means Report always takes time to focus on breast cancer during October for Breast Cancer Awareness Month, but as you all know, this is a topic that touches so many of us, and is something that we should talk about year-round. And so today we’ll cover a lot of information on breast cancer, like the signs you can look for, when to be concerned, and what it takes to diagnose breast cancer. And I can’t think of a better guest to have with us, than Dr. Josh Rafoth. Dr. Rafoth is with the University Breast Health Imaging Center. He’s a radiologist by trade, and he’s one of the first lines of defense when it comes to detecting and treating breast cancer.

Brad Means: Dr. Rafoth, thanks for taking the time from your busy schedule to be with us.

Dr. Josh Rafoth: Absolutely, Brad, thank you for having me. And I’m glad to be here today talking about breast cancer.

Brad Means: Me too, and we appreciate you and your team, and what you all do to help us, and help the people in our lives who are battling this disease. My question is something that seems like it’s changed over the years. And so you tell me, how often should a woman get a mammogram, and what age should she start?

Dr. Josh Rafoth: That’s a good question to start off with. There’s been a lot of controversy around that, but I’m gonna keep it simple. I don’t find it to be a controversial really, you know, question. Women should start getting screened at age 40, and they should get a mammogram every year thereafter, as long as they’re in good health. Some women should start earlier, if they have a strong family history or other risk factors, but start at 40 and get a mammogram every year, as long as you’re in good health.

Brad Means: Yeah, we’ll take a look at some of those exceptions to that start at 40 rule, as our time together continues. So we’ll circle back to that. But let me just ask you about the procedure itself. Is it something that you do, or do you let a technician handle it, and then the doctor comes in later?

Dr. Josh Rafoth: So the actual image acquisition is done by a technologist. They’re especially trained to acquire the images. So they do the positioning, take the pictures, and then they bring them to the radiologist. And we look at the images, and interpret them. If we need any more images, we have the technologists, you know, go back in and do additional imaging as necessary. So they take the images, we interpret them. Now with breast ultrasound, it’s a little different. We are directly involved hands-on, with that a lot of times actually scanning the patient ourselves.

Brad Means: How long does it take to get a mammogram, and does it hurt?

Dr. Josh Rafoth: So it takes about 15 minutes to acquire the images. And it’s uncomfortable for a lot of women. You know, you have to compress the breast, and it’s an uncomfortable position for a lot of women. But I will say most women say it doesn’t hurt. It’s not a painful experience. Most women tolerate it very well. And you know, they come back every year to get their mammogram ’cause it’s uncomfortable, but not painful.

Brad Means: All right, so we’re starting to get a feel for what it’s like when a woman finally makes that appointment, hopefully starting at age 40, and comes to see y’all. What about the frequency of mammograms? Let’s say you do start at age 40, and then you, you know, 30 years later, you look back, you’ve done it by the book every year. Does that put you in danger of getting cancer? Do the mammograms, in the end hurt you?

Dr. Josh Rafoth: So, yeah, it’s a good question. You know, mammograms are you know, acquired with ionizing radiation, which it is radiation, like an X-ray or a CAT scan, but it’s a very, very low dose of radiation compared to those other exams. You know, when I’m talking about the radiation exposure from a mammogram, I compare it to, you know, if you took a plane trip somewhere, and were at a higher altitude on a plane, you get, you know, additional radiation exposure just at being high at a higher altitude. The dose from a mammogram is more akin to that than anything else. Or like if you live in Denver, a city with a higher altitude, you get more radiation exposure all the time. And you know, the level of radiation from a mammogram is comparable to those amounts of radiation, which really even the cumulative dense is a very low likelihood of being harmful. And the benefits which are, you know, finding breast cancer early, far outweigh any potential harm from the radiation exposure.

Brad Means: Yeah, you’re right. I think that’s what we all need to remember today. You know, that’s the headline, is that it helps you avoid or catch breast cancer. You mentioned ultrasound a minute ago. Have mammograms and similar scans changed over the years? Can you see a 3D image of the breast now?

Dr. Josh Rafoth: Yeah, that’s relatively new technology. It’s been around a good 10 years. But 3D mammograms are kind of the cutting edge now. They are very similar to what women think of as a regular mammogram. But what they do is take pictures through the breast that we can look at, like we’re looking at the pages of a book. So we can kind of flip through these images, and look through the breast tissue more thoroughly, and find some of those cancers that may be trying to hide in the breast tissue. So yeah, 3D mammograms is a great tool we have. And in most facilities in the Augusta community have started doing 3D mammograms.

Brad Means: All right, so how old can a woman be, or should a woman be when they can stop getting mammograms? Is there a specific age?

Dr. Josh Rafoth: There’s not. I don’t quote a specific age. It’s really hard to put your finger on that. You know, it’s more a matter of your overall health. Really, we think about it in terms of kind of life expectancy. You know, if you have a 10 year life expectancy, and you’re in pretty good health, you should probably still be getting yearly mammograms. You know, if your health has declined, and you know, whatever age you are, if your health is to the point where, you know, your life expectancy has probably gotten under that 10 year mark, it’d be perfectly fine to stop getting mammograms. Now, that being said, a lot of women just are uncomfortable. Maybe you have that conversation, and say, you know, you can stop getting mammograms, but they’re not comfortable with that. That’s perfectly fine. You know, if it gives them peace of mind, they can continue getting the mammograms indefinitely.

Brad Means: You know, sometimes we see University’s Mobile Mammography Unit around town. Is the technology that you have inside that vehicle just as reliable as what I might find if I come to your office?

Dr. Josh Rafoth: It is, it’s exactly the same. It’s the same equipment. We actually converted the mobile to 3D imaging last year. So we’re 3D in the breast health imaging and on the mobile. It’s the same group of technologists. Some of them go out on the bus, and they rotate inside as well. Same radiologists are reading those exams. So it’s exactly the same. Really the biggest difference is, it’s quicker to get it down on the bus. You’re in and out faster. It’s more efficient, because you get on the bus, you check the end, you get your films, and you’re done. So it’s probably the fastest way to get a mammogram in town.

Brad Means: How have y’all been doing during this pandemic? Did it keep a lot of women away, and delay their mammograms that they should be getting? And then, to follow up on the pandemic question, what about the vaccine itself? Have you noticed any issues that it is having when it comes to breast cancer detection?

Dr. Josh Rafoth: Yeah, certainly I’ll take the first part of that. Initially, the pandemic certainly affected our ability to screen women. In March, you know, the initial onset of the pandemic in 2020, we had to stop doing screening mammograms. We stopped for about two and a half months, and pretty much everywhere across the country did the same. So we got behind, a couple thousand screening mammograms during that timeframe. So we had to work hard to catch up since then. And we have, but, you know, I’m afraid some women probably got lost in the shuffle during that, and maybe never rescheduled their mammogram. So I would encourage anybody that maybe missed their mammogram in 2020, or any time to just schedule one, and get back on board with it. It’s okay if you miss a year or two, or five for that matter. Just whenever you’re ready to get back doing it, I encourage women to get back on board for a screen. And the second part of that question, with the COVID vaccine injection, we have noticed a small number of women end up developing lymphadnopothy, or enlarged lymph nodes in the armpit usually, but can also be in the supraclavicular area. And it’s usually the same side where they had the injection. And we’re well aware of that, so don’t let that keep you from getting your screening mammogram. I would stay on schedule if you can.

Brad Means: Gotcha. All right, so hopefully ladies, and those who have loved ones in their lives to whom this applies, you have a feel now for what an exam is like, what you go through when you call, and set up an appointment for a mammogram. When “The Means Report” continues, we’re gonna talk to Dr. Rafoth about what happens if something is detected. What can you and your family expect? And what kind of support system is there for you? Covering breast cancer today, on “The Means Report.”

Part 2

Brad Means: Welcome back to “The Means Report.” We’re talking about breast cancer today with Dr. Josh Rafoth. He’s with University’s Breast Health Imaging Center. And he does a lot of work to help women who are dealing with breast cancer to be at the forefront of early detection. And so he’s sort of walking us through the whole process today. Dr. Rafoth, let me ask you this. What about when a woman’s at home before she makes the call to you, or to her primary care physician? What should she look for during breast self-exams that might signal the need to go get a doctor to take a look?

Dr. Josh Rafoth: Sure well, the symptoms that we want women to be on lookout for include any change in the breast, the way the breast feels, that they feel a discrete lump, or even a thickened area, or firm area that just feels different to them. Women are really good at detecting change on their self-breast exam, or even if they just kind of notice a change, you know, in the shower, or any other way, they they’re pretty good at detecting change in their breast exam. So really any change should prompt them to let their doctor know.

Brad Means: All right, so let’s talk about when you enter the picture, and you’re reading a mammogram, or an ultrasound, or any other image that you have, what are you looking for that lets you know that something’s not right?

Dr. Josh Rafoth: Really, we’re on a mammogram, we’re looking for either a mass or calcifications that’s a change in the breast. You know, if we have priors, we’re always comparing with the priors and looking for change is critically important. So that’s why it’s so important to get a mammogram hopefully every year, or at least periodically, so that we can compare and look for change. That’s really what we’re looking for is change over time. And that’s how we detect early cancer. We wanna detect it as early as we can. And screening mammograms allow us to do that.

Brad Means: What of the breast, where does breast cancer occur the most? What part of the breast?

Dr. Josh Rafoth: Well, cancer usually arises from the milk ducts in the breast, and the most common breast cancer subtype is ductal carcinoma, ductal cancer. It can also arise from the lobules that produce the milk, and that’s called lobular cancer. But it usually, most of it arises from one of those two anatomic structures, and it’s detected pretty similarly, honestly. But it arises from the duct or the lobula.

Brad Means: Does a mass, Dr. Rafoth, or a lump hurt, or can it be painless?

Dr. Josh Rafoth: So we most often think of cancer lumps to be painless. Usually it’s just a lump, that’s not painful. It may be a little tender or sore, but usually not terribly painful. But now that being said, occasionally breast cancer can present as a painful lump. It should be reassuring, if you’re having pain, but don’t let that keep you from letting your doctor know about the lump. They definitely need to be aware if you notice a change, whether it’s painful or not.

Brad Means: And then what about from your vantage point? I know you mentioned that ideally, you’re looking at something year-to-year, and trying to detect any change. If you do detect something, can you tell if the cancer, or whatever you’re looking at, has spread to other parts of the body?

Dr. Josh Rafoth: When we see a woman in the Breast Center, we really just look at the breast, and the axilla, or the armpit area where lymph nodes live. And so those are the only two areas we’re evaluating. But whenever we see a mass in the breast that looks like it might be a cancer, we did evaluate the axilla, and look for any enlarged lymph nodes. So we get pretty good information on both the breasts and the axilla nodes, when they’re here seeing us. And if a woman needs additional imaging after the fact, there are whole body scans. But that comes later, if necessary.

Brad Means: How long does it take you to deliver the results of a mammogram to the patient? And does it depend on what you find? Does the speed of that response depend on what you find?

Dr. Josh Rafoth: It really depends more on the type of mammogram. With the screening, the woman comes in, gets the pictures, and we read it usually within 24 hours. And then they either get a letter letting them know everything’s okay, or a phone call, if they need to come in for additional imaging. Now, if a woman comes in for what we call a diagnostic mammogram, if they’re having any symptoms, or are here for any particular reason, other than just screening, they get the results right there, before they walk out, we give them the results. And most of the time it’s good news. It’s, you know, everything looks great. But if they need a biopsy or anything else, we talk to them about that while they’re here. And we can usually get them scheduled for that, you know, either same day or next day as well.

Brad Means: Can we read anything into the length of time it takes to get one of those letters, Doctor? In other words, if a couple of days have passed, should we start to presume that it’s gonna be bad news? And conversely, if we get a letter the next day, then we know it’s gonna be good news from y’all?

Dr. Josh Rafoth: No, the timeframe to get the letter has no bearing on the what’s in the letter. But really if they have an abnormal mammogram, they’ll get a phone call. And usually the phone call is gonna be made before they get that letter. We’re pretty good about making that phone call pretty quick. So once they have an abnormal mammogram, usually we’ll get a phone call first, before they get the letter to schedule that additional imaging, whatever is needed.

Brad Means: Can you miss things? I’m sorry to interrupt you. I know these, these Zoom calls are tough when it comes to having a typical back and forth. Can y’all miss things on your end? And have to go back and either do another test, or maybe the woman returns and says, “Look, something’s still not right.”

Dr. Josh Rafoth: Certainly that’s an important point to make. Mammogram is very good, but it’s not perfect. It’s not a 100 percent. You know, it doesn’t detect all cancers. Some cancers, mammogram just doesn’t detect. So we have other kind of adjunctive screening tools that we’re trying to implement in the community to help catch as many cancers as we can. Screening ultrasound and screening MRI are two things that we’re trying to educate the community about. Make sure that we’re getting those women that are appropriate into those additional screening programs.

Brad Means: Why do you sometimes tell patients to just wait and come back in six months or a year, and we’ll check things again? If you detect something that may be a little bit different than the last scan, and you say, “You know what, we’re just gonna watch this for a while.” I think sometimes that makes women scared for the next six months to a year. But I know that it’s something that you feel you should do. Can you sort of walk me through that?

Dr. Josh Rafoth: Certainly, there’s really pretty specific protocols for what abnormalities fall into that category. We call it the probably benign category. But if we put something into a followup, like a six-month followup, three-month followup, that means we’ve determined there is very, very little chance that it’s cancer,. Like, you know, less than 1% chance, usually. If there’s just the slightest bit of doubt, we will follow that up. But if we really think there’s a chance, something could be cancer, we’re not gonna do the six-month followup. We’re gonna recommend a biopsy, and do a biopsy, if we think there’s much of a chance that it could be cancer.

Brad Means: Okay.

Dr. Josh Rafoth: So, almost all followups turn out to be just fine.

Brad Means: Yeah, no, that’s helpful, and I appreciate it. Are some women more susceptible to breast cancer than others? And if so, what can those women do to reduce their risk?

Dr. Josh Rafoth: Certainly they are. And you know, family history is a big part of that. If you have a strong family history, you’re at increased risk. There’s several other risk factors. If you’ve had a prior biopsy that showed atypia, or if you have like a BRCA mutation, you’re a very high risk. So there’s a subset of women that are at increased risk, and we would definitely want them to have a good dialogue with their doctor, and get plugged in with a breast specialist, a breast surgeon, if they would like, to make sure they’re staying on top of things. We can offer additional ways to screen the breast in those women. Breast MRI is one great tool that we have to screen high-risk women. We do it in addition to mammogram, and MRI is a great tool for those women that are higher risk.

Brad Means: Let me ask you this about breast cancer treatment. Has it changed over the years? Has the approach that you all take after that initial diagnosis changed just in your career?

Dr. Josh Rafoth: It has. I’ve been doing this for about 12 years, and I’ve seen changes all along the way. You know, really, I think that to kind of sum it up, we’ve tried to really individualize the care to the particular patient, and their particular cancer. There’s not a one size fits all model for any of this, for the screening or the treatment of cancer. We can really tailor the approach very specifically to that patient. And therefore, you know, we try not to over treat a cancer that may be a more indolent, slow growing cancer. And we get aggressive if it’s a higher grade cancer that’s more likely to cause trouble. So we really individualize the treatment depending on the patient and their particular case.

Brad Means: But chemo and radiation are still the go-to methods. Would you say that’s true?

Dr. Josh Rafoth: Well, surgery is probably the you know, the primary treatment method. And then radiation sometimes is involved, and chemotherapy as well. But we’ve done a lot better job of figuring out who benefits from chemo, and who doesn’t. So a lot of women don’t get chemo because their cancer, we can actually check their cancer, and see if it’s a cancer that you know, basically needs chemo to make sure it doesn’t recur, and decide who would benefit from chemo, and who wouldn’t. And then we also have hormone therapy, anti-estrogen therapy, which is a very important part of treatment these days, as well.

Brad Means: I wanna go back to the breast self-exam question real quick, if I may. And it’s just this, if a woman finds a lump, or some sort of what she perceives as an abnormality during a BSE at home, should she be alarmed? Should she think, this is cancer?

Dr. Josh Rafoth: No, most of those are not cancer. Most of those we work up, and we’re able to give good news before they leave. It’s either a cyst, or normal tissue, or one of any other of a number of things. But, so I don’t want ’em to be alarmed, but I do want them to pay attention to it. See if that stays a long for, you know, a week, or two, or a month. And if it does persist, I want them to let their doctor know and not wait any longer than about a month, or, you know, maybe through a menstrual cycle or two, and see if it goes away. But then I want them to let their doctor know.

Brad Means: Probably my last question, Dr. Rafoth, and it’s just to get you to talk about some of the exceptions that would require a woman, or a girl, to come see you sooner. I know you said 40 years old is sort of the baseline when women should start having yearly mammograms. When might a female need to come to you sooner?

Dr. Josh Rafoth: It’s a good question. We use something called the 10-year rule. If you have a family history, your first degree relative, either mother or sister with cancer, take whatever age they were diagnosed, and go back 10 years. And if that number is under 40, that’s when we want you to start screening. So if your mother had cancer at 45, we want you to start at 35. We really don’t know under the 30-year age. We wouldn’t ever start screening for the most part, before 30. But, you know we would want you to start in your 30’s, if your mother or sister were diagnosed in their 40’s.

Brad Means: All right, that’s extremely helpful, as has all of your information been today. Dr. Rafoth, thank you for what you do for the women in our lives. And in some cases, the men in our lives, that’s for sure. We appreciate you, and really appreciate you taking the time to explain breast cancer, and everything that surrounds it with us today.

Dr. Josh Rafoth: Thank you, Brad. I appreciate the opportunity to speak. And it’s always important to get awareness out there, and to get more women in screened. It’s an important part of what we do.

Brad Means: Point so true. Thank you so much, Dr. Josh Rafoth, with the University Breast Health Imaging Center, our special guest today.

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