Baptist Health’s High-Tech High-Touch Approach - Live Webcast on Breast Health
Originally Broadcast: Wednesday, May 31, 2023 | 5:30-6:30pm ET
Join Baptist Health experts for a webcast focused on breast health; beginning with imaging through the continuum of care at Miami Cancer Institute.
Baptist Health’s Dr. Katharine Lampen-Sachar and Miami Cancer Institute’s Dr. Jane Mendez will lead an interactive discussion on:
What physicians need to know regarding breast imaging at Baptist Health
Which imaging test is appropriate for your patient
Patient navigation at Baptist Health
Patient referrals to Miami Cancer Institute for breast biopsies & beyond
Good afternoon, everyone. Uh Thank you so much for joining us this uh late afternoon. My name is Christy Fleas. I am with Baptist Health South Florida Physician Business Development team. Uh I am the lead for Miami Cancer Institute and we are definitely very excited to have you all join us for today's uh high tech approach on breast. Uh We will be discussing uh many um that would be very pertinent to your practice and to your patients regarding our diagnostic imaging specifically for breast and what how the pathogen journey leads into potentially Miami Cancer Institute and our breast cancer team. Uh With that, I would like to introduce to you all our two physicians that will be providing the presentation for you all this afternoon. I'll first start with doctor Catherine uh Lamps Saer. Uh She is our section chief of breast imaging for Baptist Health Diagnostic Radiologist. Of course, she specializes in breast imaging, 3d mammography, breast ultrasound. We also have breast MRI S that she focuses on Doctor Lamin Saer also performs uh image guided per breast procedures, uh specifically stereotypic guided needle biopsies, ultrasound, guided breast biopsies, and MRI guided breast biopsies. As Well, before Doctor Lamb Beacher joined Baptist Health South Florida, she was an associate professor of radiology and assistant attending Radiologists of breast and body imaging at New York Presbyterian Hospital. Um Will Cornell. Uh She is also a reviewer of multiple journals, medical journals. She is very passionate about educating the next generation of physicians. In fact, she is currently in the process of developing Baptist Health first diagnostic uh radiology residency program, which should be kicking off in 2025 and she will be serving as our program director. Um And as Doctor Lander, you will be hearing from Doctor Jean Mendez. Doctor Jane Mendez is our chief of breast surgery for the Miami Cancer Institute. She is board certified and fellowship trained specifically at New York Memorial Sloan Kettering Cancer Center where she did her fellowship. She does specialize in the treatment of breast cancers. She performs all types of breast cancer surgeries um and procedures. She did her undergrad from Harvard University and her medical degree was at Mount Sinai School of Medicine in New York. Uh Before also joining Baptist South South Florida with Miami Cancer Institute. Doctor Jane Mendez was a surgical oncologist at Boston Medical Center and amongst her time there and other roles, various roles. She was the president of the medical medical and dental ST at um Boston Medical Center. She has contributed notable uh breast cancer research and her findings have been published. One of the very important roles that Doctor Jane Mendez has with us is that she does participate in many uh organizations. She does multiple symposiums, both national and international. She is a fellow of the American College of Surgeons and Doctor Jay Mendez is very passionate about educating patients um and advancing breast cancer uh cancer awareness. So with that, I'd love to turn it over to doctor Lamb so we can get started on this afternoon's presentation. Good evening. Uh Thank you so much. And I'm happy to be here to share a little bit of more about breast imaging and uh hopefully answer some common questions that come up regarding ordering practices. I'm really excited to chat about this slide and this is one that I can talk about all day long. But several weeks ago, the US PTSF actually revised their guidelines regarding breast cancer screening and we made a lot of progress. Is it perfect? No. Um but the US PTSF now agrees with, I would say the majority of this slide. So for average risk women, we recommend annual mammography starting at age 40 stopping when life expectancy is around less than five years or at the discretion of the doctor and the patient. A lot of really good quality organizations agree with this recommendation. As you can see the one modification that, that the US PTSF made with their revision um was they first said start at age 40 but they said do mammography every other year. I won't bore you with the details on why I think annual is dramatically better than every other year. Except to say that there is ample data supporting annual mammography and from an anecdotal perspective as well. I've seen tremendous impact from one year to the next. And what happens when you skip. I wanted to take a step forward. Now after doing a quick review of these screening guidelines to go into a little bit more of the nuts and bolts regarding screening mammography versus diagnostic mammography because sometimes it can get a little bit confusing. So in general, screening mammography is going to be for the vast majority of our patients. It's asymptomatic women. It can also be for women that have nonspecific bilateral breast pain. And we all have plenty of these patients where they can't quite pinpoint, it's just kind of generalized. They belong in the screening mammography bucket and no significant risk factors. And this is a table that's adopted from the American College of Radiology, the AC R and we basically have appropriate niceness criteria um which is all data driven on what the best study is for basically every single clinical concern out there. So for a woman that is of average risk of developing breast cancer, which means around less than 15% lifetime risk, we recommend annual mammography. They separated screening mammography, two D versus 3D. Baptist were all 3d. So all the better. Um So we recommend screening mammography for average risk. Asymptomatic women, diagnostic mammography is really our primary study in a patient that has clinical symptomatology. So what might that be a palpable? You feel something new or the patient feels something new? Vocal breast pain? So I call this the index finger test. I ask if the patient can put their finger on the specific area, that's both them if they can. That is focal breast pain and warrants a diagnostic mammogram. If the patient has unilateral clear or bloody nipple discharge, those are worrisome findings that absolutely warrant a diagnostic mammogram. It, it can be ordered as a primary study in a patient with risk factors or who has a personal history of breast cancer and it's the primary study for male patients. Um At this time, we do not order screening mammograms on male patients. Um importantly, um and I'm sure everyone has seen this. We recommend this as the secondary study in a patient with an abnormal screening mammogram in order to work up the finding. So we have an asymptomatic female that comes to us for a screening mammogram. We see a small finding. We'll give that a by rad zero recommend additional imaging. And typically what we'll recommend is a diagnostic mammogram. As the ordering doctor, you don't need to worry about what specific um images we're gonna wanna get. We take care of those details. The important thing is the diagnostic mammogram part. And then finally, we may do a diagnostic mammogram as a primary study and a follow up to a patient that had a prior probably benign or bira three mammogram. So I wanted to hopefully go through some quick clinical um scenarios um that I think most people come across probably on a daily basis. So here's one that I see all the time. It's a 40 year old female who has a new self detected palpable abnormality. Um And they call up your office and ask what to do. Well, if you're able to evaluate the patient, fantastic, if you're not, I recommend ordering a diagnostic mammogram um that has the highest rating according to the AC R appropriateness criteria. And then typically what I will recommend doing is ordering a breast ultrasound to accompany it. What may happen is we may see a mass on mammogram. The trouble with that is great. We identify the mask. Now we have to figure out what's inside that mask. Is it a simple cyst fluid or is it a solid mass? And that's where ultrasound is going to be very helpful. So 40 year old female, new palpable abnormality, diagnostic mammogram and ultrasound are the most appropriate imaging studies to order. In contrast, 25 year old female who has a new palpable. Um We see a lot of these as patients are now becoming more and more uh conscious of their uh medical health and starting to do more and more of their own breast exams. So for a 25 year old patient that presents with a new palpable. We're gonna recommend that they start with the breast ultrasound and the rationale behind that, um which is data driven is that the vast majority of what we see in a 25 in young patients are going to be benign findings like cysts or fibrocystic, fibrocystic changes or sometimes fibroma. We will then if we see something worrisome, we may then recommend a mammogram. But we would first start with an ultrasound. And then here's one that I actually do come across not infrequently a male patient who's older than 25 who presents with a palpable mass or maybe even gynecomastia. The best way for us as radiologists to make a diagnosis of gynecomastia. Interestingly is a diagnostic mammogram. Ultrasound is sometimes like I could take it or leave it. But a diagnostic mammogram really in the vast majority of cases will answer the question. Um We actually recently started on men that are presenting with palpable findings doing tomosynthesis on them, which has been um helpful and may provide some additional information. But the best study as you can see, the one that says usually appropriate is going to be a diagnostic mammogram. Breast ultrasound, sometimes can follow the diagnostic mammogram. But number one is a diagnostic mammogram and I can tell you that sometimes when patients come in men and they start with the breast ultrasound, it becomes very confusing and we actually then need to then go and request a mammogram to try and figure out are we seeing dense tissue? Are we seeing shadowing from the nipple or is this just gynecomastia or is this something more worrisome? So when in doubt a diagnostic mammogram? So I've sort of alluded to this but and I would say the data is not quite as robust, but a lot of questions arise on when to get an ultrasound. So, symptomatic women should absolutely get an ultrasound. If they have palpable nipple discharge, skin changes, some sort of nipple abnormality, maybe they've noticed new nipple inversion or breast pain like that index finger test, it's frequently indicated in the work up of a mammographic finding. So specifically, you might read in the report um where we're recommending additional imaging. Um we may see a soft tissue binding and we'll use some of the terminology like an asymmetry or a focal asymmetry, architectural distortion or a mass ultrasound's gonna be helpful for us in addition to the mammogram and we'll specify in the screening mammogram. If we think the patient needs an ultrasound for us to better evaluate the finding. Patients who are at intermediate risk of developing breast cancer, they're not quite high risk, which we classify as 20% or greater lifetime risk of developing breast breast cancer. But they're not really quite when we do the calculation low lower risk in that one in eight women kind of categorization. Women that are intermediate risk may be benefit from a breast ultrasound. In addition to mammography, additionally, there is some data to support doing it in any symptomatic women with dense breasts. So those would be patients that have that breast composition of heterogeneously dense or extremely dense. So in women who have dense breasts, we find an additional 3 to 5 cancers per 1000 women screen. When we add it. In addition to mammography, not as a substitute, there is really zero data to support the use of ultrasound as a screening tool in women who do not have dense breasts. So those that have breasts almost composed entirely of fat or composed of scattered fibroglandular densities. And so here is sort of how we can picture the why. So on the left, we have the breasts are almost entirely fatty and all the way on the right of that first picture, we have the breasts are extremely dense. Breast cancers in general are white. So you can see how in that extremely dense breast, if we were to try to pick out a tiny four or five millimeter white cancer, it would be pretty hard to do. So those categories press composition category C and D heterogeneously dense and extremely dense. Those are the patients where we're gonna find extra cancers by adding an ultrasound. In contrast, the breast are almost entirely fatty. This patient here has just like a few tiny white wisps of tissue. The rest of it is entirely fat. We're gonna be able to see those small white cancers even 2 to 3 millimeters in that fatty breast ultrasound is really offering very little for those patients and it offers very little for that scattered fibroglandular density category as well. I think it's also important to note and I try to emphasize this with my patients because they sometimes get upset. Oh, is there something wrong with me? I've been told I have dense breasts. No, the answer is no half of the pop of female population have dense breasts and it's basically a benign thing. We're saying, half of women in the world are walking around with dense breasts. There's nothing wrong by with the patient's breast by having dense breasts. It just means we may need to be a little bit more vigilant. So what to tell your patients and maybe it's the patient that's scared to get the screening mammogram. Um And maybe this will assuage some of your concerns. Um As there have been a lot of discussions regarding reported quote over diagnosis, which we could have a whole webinar dedicated to that and whether or not that's a real uh entity out of every 100 women who get screening mammograms, 90 of them are gonna be told that their mammograms are normal. So 90 of them are gonna be able to log into their patient portal and say I'm good until next year, there will be 10 that will be asked to return for additional mammograms and ultrasounds. The most 60% of those are then gonna be reassured that their mammograms are normal when they come back for the additional work up. Two of those. So two out of 100 are gonna be asked to return in six months for a follow up exam. And really only two or 2% of patients will be recommended to have a needle biopsy and not all of those two will end up having breast cancer. But it means their findings are warrant a biopsy c because they're really sort of indeterminant. And we can't make the distinction with the imaging that we have. So I wanted to order just some general ordering uh rules of them. The vast majority of patients require a screening mammogram. If it's their first mamo start with the screen, we'll tell you if it should be different in the years going forward, we indicate breast density and if the patient has dense breast to consider a breast ultrasound and then going forward in subsequent years, we know if the patient should have an order for an ultrasound because you'll know what their breast density is from their prior imaging reports. Patients who are older than 40 with palpable, absolutely need a diagnostic and mammogram and ultrasound at the same time. And then I I would just offer, I'm very wary of the PR N ultrasound order and I, you know, take this back to when I was an intern and um was listening to uh a coin intern. Uh and they're saying I'm putting in an order for all these IV antibiotics pr N, I mean, we obviously don't do that. So, um I think of all APR N ultrasound order as APR nib antibiotic order. And then I wanted to use this sort of final slide as my segue into biopsy. So you have a patient that calls you up and they're very concerned because they've been referred for a biopsy. So those will be patients that fall into our categorization of a BIRADS four or a BIRADS five. The vast majority of patients are going to be BIRADS four, which means we think that there is between a three to a 94% chance of malignancy, which is huge. So I think for the most part, it should be very reassuring because a lot of those patients are gonna be in that lower percentile. Uh Category five means we're really suspicious that it's gonna be a cancer. Um And so in our diagnostic mammogram or ultrasound report, we will make a recommendation for biopsy and we'll specify the best manner to biopsy, the area. Um There's no guesswork. We'll specify whether or not it should be a stereotactic guided biopsy, which uses mammogram to guide us an ultrasound guided biopsy or so rarely an MRI guided biopsy. And there's no guesswork. And the reason is because we're taking the time to figure out what's the best way to see the finding and what's the best way to access it in the most comfortable way for the patient. Um So if we say that it's really a stereotactic guided biopsy, it means ultrasound, guided biopsy, unfortunately, just won't be helpful in getting to the area that we need to get to. Um, and then just sort of to close, um, all of our reports by law will give a BIRADS assessment at the end of each report. I certainly hope that you read all of our beautiful reports in a ton of detail. But if you don't and you just want to know what to do. Look at the very bottom of the report and it will specify exactly what needs to happen by Rad's category two. Return to mammography by Ira's category three, probably benign. We will indicate what the follow up study should be to better evaluate the area at short interval, follow up. Um and then just to close. So what happens a patient gets referred for a biopsy? They get picked up by our biopsy team by our breast care coaches and our specialized schedulers for breast biopsies, they'll receive a phone call within 24 hours of their mammogram and we'll help to get them put on the schedule. Our team then reaches out to your office to help facilitate getting the prescriptions um for the biopsy, we check in with the patient prior to them coming for the biopsy. And then we do the biopsy and then we have a whole slew of postbiopsy um care that we provide to the patients. So those were the main little takeaways that I wanted to share with you tonight. Um I think we're gonna save questions for after Doctor Mendez's uh presentation. Thank you so much. Good evening, everyone. Thank you for spending part of your afternoon with us to discuss this important topic. And as you've heard from Kate, you know, the breast imaging is really the first step towards really figuring out what's going on with our patients, breast complaints. And my job over the next few minutes is to talk to you about the breast services that we have available uh at MC I as part of our Baptist Health. There we go. So I have no relevant financial disclosure. So in the next few minutes, I'd like to talk about the multiple approach to breast cancer treatment and what we have here under one roof, individualizing breast care patient centered approach, as well as the breast cancer prevention clinic and the benign breast clinic. With that, this is what the space looks like for those of you who haven't been here. So there is a very open space, very welcoming and on the second floor, that's where you find the breast clinic as well as the breast imaging services. With that. I wanted to let you know that 20% of all the cancers that are treated here at Miami Cancer Institute are breast related. So it's really a very important entry point for a lot of our, of our patients. And it is a fact and I guess nobody will argue with me that once you have any of your patients feel a lump or, or any breast abnormality is really an anxiety provoking moment. And there's a source of urgency about the symptoms. But we have a fundamental task as physicians to determine whether the abnormality is benign or malignant. And as um Kate already very eloquently described, you know, every patient who walks through our doors is a very unique experience. Certainly the breast imaging service is that key point where depending upon the underlying abnormality, they're all experts at what they do. And they're really the first step where we can make that distinction if this is something that we need to worry about or if this is something that is completely benign and doesn't require any further work up. So at the crux of really figuring out and giving either some reassurance of the patient, but we have to do it with the state of the art, which is certainly the image guided procedure because we really want to be able number one, if it's something completely benign, the patient might be completely done. If it's something that is a typical, that might require increased surveillance, then we can really place the patient in the right place. And if it's a cancer then we can perform a cancer operation. And she really gives us the key information that we need to really care for that particular patient. And obviously, once it is determined to be a cancer is a multidisciplinary approach to that cancer care. And every time that I have this presentation, I have to put more elements to this complex slide because certainly it keeps growing, but it's all interdependent. I cannot do my job or none of us as surgeons can do our job without the incredible help from our breast imagers because they really guide us on what we need to do. If there's something multifocal multi unifocal, is there something of concern in the lymph nodes? Do they require additional imaging to help us better guide the operation and not to talk about the importance of knowing it used to be very simple. In the past, the patient has surgery, then we have a very limited options of chemotherapeutic options. Then came radiation. Then if the patient had an er positive tumor, they would take tamoxifen of an endocrine. And if not, if it was an er negative, there was not much more that we could offer that patient. But nowadays, it's no longer that simple and we need to really, we know that one size does not fit all and we have to individualize the therapy and this is what it might look like. Now, a lot of patients are receiving new avant chemotherapy. Uh So shrink the tumors or the dance is the, we have a plethora therapeutic agents that we can choose from depending on the tumor biology as well as targeted therapies that we have. Now, we have other options other than the ox and the amo inhibitors and trying to even longer periods of treatment provided the patient is tolerating the treatment. Well, so that's the importance of the individualized treatment. And we also have a much better understanding of the heterogeneity of breast cancers. And that is also a starting point with the biopsy that our best images will get us understand what is the tumor biology was that will further define how we're gonna optimize the treatment for that particular patient. We can use genomic profiling in a lot of these settings to help us decide on what is best. Let it be nevan chemotherapy first versus surgery first. And every Friday, we have our multiple breast tumor where we actually we discuss difficult cases real time, including the imaging, the pathology, the genetics, if they're their candidates for research. So we can really as a team determine what's best for that particular patient and their tumor biology. And sometimes it's not that easy, you know, the decision about chemo versus no chemo. You know, we can use these genomic profiles to help them make those decisions as we're trying to aim to maximize the cure. But at the same time, we don't want to cause unnecessary burden because with every treatment, there's potential risk. So we're all looking for these targeted treatments, you know, for the her to positive patients. We have a lot of options available. And as you know, the holy grail in breast cancers, those triple negative breast cancers were were very significant area of research where we don't have a specific target yet that we we have for the two or the ear positive tumors. So this search is ongoing and the beauty is that here, everything is under one roof. And certainly I have the privilege to work with a very experienced and talented group of uh breast surgeons. And as you can see, Doctor Robert Glad, Cristina Lopez and Tom Mountain, all of them have been here a long time. All of our extremely passionate and dedicated to our optimal patient care and an excellent patient experience, but we couldn't do our job without the rest of our colleagues, you know, medical oncology. You know, we have Reshma Matai Francis, Aman Lauren carcass grace one. And there's a new addition to our family, Naomi Dempsey, who's our plantation location. But all of these individuals really help us decide from the medical oncology standpoint. What's the optical treatment? Are there any other side effects or risk that we need to consider before we decide what the best surgical option and not to talk about our breast radiation oncologist Dr Fagundes Pao, you know, Amelia Rodriguez and Anna Botero at the plantation location again, is there any role for radiation of the patients who are mastectomy? Certainly, after lumpectomy, we are going to in depth discussions in women, 70 older. Is it really beneficial for that patient to receive a human radiation treatment or if it's a tumor that is one as favorable characteristics? Could we forgo the adjuvant radiation treatment if the patient is willing to take the endocrine therapy? So it's the complexity of, of these discussions that we have day in and day out to really assure that our patients are getting the best care possible and not to talk about the proton therapy that we have, which has selective indications uh in breast cancer patients or for selected patients with left sided breast cancers, it could have a benefit in terms of decreasing cardiotoxicity. So again, the standard is, is not the proton, but for those patients who have certain risk factors, it's a consideration and we certainly would offer them to these patients as it becomes indicated. And certainly we have our reconstructive uh plastic surgeons. We have three of them who do uh breast as reconstructive surgery that do a phenomenal work. Uh And they are all verse in either implant babies or auto tissue reconstruction. And it's an in-depth discussion that they'll have to the patients about the pros and cons of all the different types of reconstruction available. I just wanna say now a couple of words about benign breast clinic. So I really wanted to create a portfolio of different breast services that would fit the patient's needs. So, the minimized breast clinic we created several years ago with the idea to cater to all those patients that who do not have cancer nor any high risk pathology conditions. So this would be an indication for patients who have a benign omma, who might have a non bloody ale discharge, who might have those pain fibrocystic breast changes. So we have a whole list of criteria and those patients could be seen in the bean breast clinic, which is led, uh under the auspices of Doctor Dera Goin and one of our A PP who's been doing this for years, Dorado. Then we also created uh almost four years. Now, the breast cancer prevention clinic and that deer for patients, uh, skate alluded to have greater than 20% likely of increased risk of breast cancer. And this is meant to be for those patients who have genetic mutations that have a high risk pathology conditions, uh, who might have exposure to radiation, who might have a very strong family history of breast cancer. And by different models have been estimated to have greater than 20% increased risk of breast cancer in the future. And we coined the term pre provider, which is a term that first came about 2007. And this is when you know, these individuals let it be for genetic mutations or because of high risk pathology conditions have increased risk of breast cancer, keeping in that pre virus stage, keeping them healthy without developing the breast cancer. So that clinic has been very well received and we work jointly with radiology in determining which patients need to be seen in the high, you know, in the breast cancer prevention clinic versus the uh breast cancer clinic. So we can really improve access to these patients and really focus on their needs. We can see one cli clinic really focuses on the increased surveillance as well as chemo prevention. Talk about the possibility of a tamoxifen versus Raif as part of chemo prevention and just doing something beyond the increased surveillance for this selected group of patients. So it's an exotic discussion that they'll have with the uh you know, the physicians about what their options are. And at the end of the day, the patient can be followed and hopefully keeping that pre virus state. I just wanted to show you one of the pictures from the plastic reconstructive. You know, we are performing nila brain mastectomies. This is an example of a patient wonder when her nipples brain mastectomy, as you can see from the cosmetic standpoint is incredible what can be accomplished and our plastic surgeons are really versed in it. And the key is patient selection for many years. There was a question pertaining to the oncologic safety of the nipples, mastectomy. But certainly if the patient meets the criteria and it can safely be done. I just wanted to showcase some of the work that our plastic surgeons have done for some of our patients. But this is indeed a possibility for some patients and I would be remiss to omit a lot of the services that really support what we need. And a big issue for us has been oncologic rehab and we have two great physicians that didn't have a picture for doctor or, but Adrian Christian leads our rehab oncology efforts. And we are very keen, not only on rehabbing the patients, but pre having the patients. If we identify patients who have several comorbidities that made them higher risk or they're very frail, we try to optimize their performance status prior to surgery prior to treatment. So they can really uh do well through the treatment and thrive. And I also wanted to say a couple of words about our genetics, uh services. We have two geneticists, Maria Descartes and at least Martin de who heads hits heads that section and from the lympho, from the rehab standpoint, this is a key, we really want to avoid lymphoedema. So we have a very strong lymphoedema program. So certainly, if I know that any of my patient is gonna require an axillary lymph node dissection with increased like of lymphoedema, I will refer the patient to rehab oncology prior to surgery. So they can really learn how they can prevent lymphoedema. As the key to lymphoedema is prevention and certainly from the genetic standpoint, there's been an explosion of genetic panels that are available. We are really a privilege to have multiple genetic counselors that really do an exhaustive ge uh family tree with the patients who are referred. And the more we know about the genetics, the better decisions we can make. And certainly with genetic predisposition, it has implications in terms of the treatment recommendations. So we are very lucky to have all these genetic counselors helping us and our patients at doing the testing and helping in the decision making process. And not only about breast cancer, but also about any other cancer that may be associated with the genetic mutation identified. And it's all part of reducing that collateral damage. And also, again, we don't want to just provide a treatment because we can do it. We really want to keep that balance between that optimal treatment. We don't want to overtreat, we don't want to undertreat and it really boils down to the biology as well as trying to change dogma with a lot of things, the fact that we can do, it doesn't mean that we need to do it. And it's striking that balance which looks different for every patient again because it's not only about the patient with their own comorbidities, their own fears, their own wishes, the genetics that comes with it as well, but also any comorbidities that we need to take into consideration. So in as part of that high tech high touch. Certainly, this is only the treatment but the e does not end there. And obviously, it's all about the patient centered approach that as you know, starts with breast imaging and continues, you know, they have the breast care coaches will really lead to the patient through the biopsy process. And then our patient navigators really take them from the hand after they get diagnosed and connect them through the journey. Because obviously, it's multiple issues that we need to keep into consideration all centered around that patient with the navigation, the treatment of the SAFA quality of life issues, family friends, support groups, which we have as well and certainly is taking the patient through that journey as they go from service to service and providing the support that goes way beyond the science and the technology to helping them just as patients to get through the breast cancer journey. And with that, certainly, let me see, we have to take a look with a different set of eyes. That's why we take the time to obviously talk to all of you. We all now we have over 3 million survivors in these states. And obviously, the key is that health care begins here. We're here to support you and our community and we are under one roof. And certainly things have changed a lot over the past 30 years when it comes to breast cancer. But at the end of the day, you know, with better technology, better treatments and early detection. We obviously can achieve 98% survival at 10 years, but it all starts with Kate and her imaging team. So, thank you all for your attention. Uh Incredible presentation. Thank you again to both of our physicians. Um Some of you may be asking yourselves if you don't already know, how um do we refer a patient to schedule a patient for um diagnostic imaging within Baptist Health, South Florida? So uh there's multiple ways of doing this. We're very fortunate to have a great uh physician business development team. These are representatives from our organization that go to your offices and provide you with all the tools and resources that you, we need in order to get your patients to us as quickly as possible. So we do have our Baptist Health call center contact list which you see here on your screens. Um We will be sharing this information with you via email um as well as when we visit your offices. If you are a physician or a staff member in a physician office in Miami or Monroe, and this imaging requires authorization. It all depends on the insurance, then you have the option to email authorizations at Baptist health dot net fax or phone call. It's a dedicated team that all they do is this specific function. If you're in Broward County there, you see your email fax and phone number, just some important tips, right? Is to send all the relevant testing, appropriate documentation, depending on what you are requesting for the patient, so that we're able to get the authorizations if necessary for your patient. Um If it does not require an authorization, the process is a little bit more simple. Um And it just is a scheduling the same you have fax services um or an email where you can request the appointment and we reach out to your patient directly. Um If it is a patient that you prefer to call and schedule for themselves, that is the contact information for them there by county. And then physician scheduling line is only for our physician offices to use. And again, it's by county. Uh This is a quick snapshot. I did wanna add this on here. Uh Our organization has a diagnostic imaging form uh with all the imaging that we provide, but I wanted to highlight our women's services where you find all the different types of diagnostic test screenings that Doctor Lamp Ander mentioned in her presentation. And along with that you have the CPT codes. So it does facilitate things for you from an office, a workflow perspective and your patients in seeking the appropriate type of authorizations or scheduling those appointments appropriately. So this is a great uh tool and sheet to use. You don't have to worry about how to properly word it, how you need to write it. It's all listed here for you already. It's just basically checking off the box and you will have you see breast MRI S there as well and our breast biopsy. And then the next component of this is if your patient does end up with a biopsy and has a positive finding and therefore requires a referral to see a breast oncological surgeon or specialist in Miami Cancer Institute. This is how you get there. I highly recommend for our physicians um to use these two resources to send your patients to our team members. For example, if you were to send to one of our breast oncological surgeons, you could either call that phone number. It's a direct dedicated team for our physician offices. They are all subspecialized. So those that schedule for breast only schedule for breast and they're very well versed in the appropriateness of the needs of the patient or you can email. Um I'm going to give you my two cents. I prefer the email. Uh There's transparency, accountability and track ability through the email and you could also attach all the relevant testing. We will contact your patient. You will not be in the middle back and forth between us and your patient trying to find that date. So really this is what I call bulletproof. Um It's very successful and helps the navigation of your patients with that. We also had a few international physicians that um had joined the webinar. We have an incredible international um department that services the Caribbean South America, Central America. And they have a specific way to make sure your patients are appropriately through um the insurances that international patients have. And this is the information that you would access and they will coordinate all the care for your patient. And I'm going to start with some questions, Doctor Leaker and Doctor Mendez that we did get through. Um you both can, you know, share who would like to answer. Uh the first question that came in was wanting to know what is the process for a biopsy after there is a suspicious um mammography, ultrasound result. So I guess Doctor Li Penza, this would be for you, I suppose. Sure. So a patient comes in, I guess the scenario would be comes in for their mammogram and ultrasound and we see a suspicious finding. Um We will go in and speak with the patient and inform the patient of the results and our specific recommendations. We'll give like a brief little um description of the biopsy. The patient will get a brief form that also describes a little bit more about the biopsy. Once we issue the report, which happens almost immediately, it then gets flagged. And within 24 hours, the patient will receive a phone call from our dedicated breast sched breast biopsy schedulers to help get them on the schedule for a biopsy. We frequently have them called as well by one of our breast care coaches and these are two very experienced women um who have been doing this for years and really know the ins and outs of biopsies and can really help to kind of talk the patient through the process. At the same time that we're reaching out to the patients to help get them on the schedule for the biopsy. There is a trigger for our schedulers to also reach out to the referring doc's office and that's how they arrange to get the prescriptions, the preauthorization if necessary. All of those things when the patient comes in for the biopsy, we provide a lot of instructions, um kind of on what to expect postbiopsy care instructions, all of that as a doctor, I also spend a lot of time after the biopsy talking with the patient a little bit of expectation management. And I also try to provide my sense of what I think the outcome might be from a pathology perspective, benign or malignant or I'm not sure. Unfortunately, there are some gray zones in breast imaging and we need the little bit of tissue to figure out exactly what's going on. I tell my patients I'm an open book. If I'm worried about something, I will let them know if I'm not, I try to provide hopefully, you know, realistic expectations of what I expect it to be. Um And then typically the patients the next day will receive a phone call from one of our care coaches just to check in on them and see how they're feeling. And then the pathology typically takes 3 to 5 business days to become available. Um We have amazing pathologists but there is no rhyme or reason to why it might be one business day or why it might be five business days. And that's what I tell the patients. Sometimes things just require extra pathologic stains and it just, it just takes time and it still could be benign. Um And then they will receive a phone call from us with the results. We also confirm that your office has a copy of the results. And sometimes we know that you prefer to inform your patients if there is by chance a malignant diagnosis and our care coaches are very attuned to each individual doctor's preference. Thank you. Um The other question um that did come in is that they're seeing in their offices positions a large increase of patients in needing biopsies and in turn needing um a a breast to see them. So most of them are turning out to be noncancerous, but they are not conclusive. They're saying based on the biopsy. So they're trying to find out, have you been seeing that and why? Um as they're seeing that in their offices, well, one component that is critical uh to Kate's job and mind is making sure that the pathology is what we call concordant with the imaging. That the pathologic findings really explain what the radiologist was expecting to find on that image. So if we have what's called a discordant pathology, then the patient wouldn't need to be referred to a breast surgeon. So then they can have an excision of that area. So we can really get to the bottom line. So, but usually, you know, our colleagues in Viola have very large biopsy devices that they can use and they use multiple samples at least four or five that I know. So, you know, the the I don't know why they're observing many of these instances because right now we have pretty good concordant most of the time. So Kate, if you wanna comment, absolutely, I would say, I mean, I don't have the data, but I I personally have not noticed any increase in our discordance rate. Um As Jane was saying, um we're using pretty sign significant. They are needle devices. It is minimally invasive, but we're using for the most part nine gauge, 11 gauge, rarely 14 gauge needles. So these are not insubstantial. So the vast vast majority of time our samples should be adequate. But then it does become a question of um what the pathologist is seeing. Does it indeed match what the imaging findings are? And sometimes it can be a little challenging. Since the advent of tomosynthesis, the 3D technology, we're seeing a lot more architectural distortion. And I think that as a group of breast radiologists nationally, we are we are having to reframe our expectations regarding architectural distortion because we are seeing just so much of it that we didn't see 15 years ago. So what I learned at Sloan Kettering in my fellowship now, 11 years ago, a lot has evolved in terms of what the patho pathologic expectations would be. For, for example, architectural distortion. And I think we're gonna continue to learn interesting. And the last question that I saw um is what does, what role does A I play in reading mammals? Oh, this is such an exciting topic. Um And it does play a role and I think it will play a much greater role. Um What are we? So what are we currently using it for? We currently have a tool that's been around for a bit. That is kind of our double checker tool. We call it CAD and we have a more advanced CAD that uses the 3D imaging technology and it can help us to sort of make the decision first before we close out an exam. Oh, no. Did I miss something? And this marks it, um which I would say is rarely the case, but then it also might be um kind of on the fence. Is this something that we really should work up or not? And if the tool says yes, then it would be a good indicator to uh follow through with doing the whole diagnostic work up. There's so much being published right now on the uses of the A I and breast imaging. And there's so many ways to think about its utilization as a second reader to increase efficiency, increase diagnostic accuracy, better triage patients. Right? Like, wouldn't it be amazing if we had an A I scheduler that could say correct, incorrect. Yes, no push to this one. Get them in quickly, you know, like I think that um there's a lot of potential there. Um but it's all still rapidly evolving. Um And one area that I'm really excited about, um which I'm hoping will be on the horizon for us soon is as part of an A, an A A I tool that does with some of the mammographic things, it will actually take a look at the patient, the pixels, the actual mammographic pixels and very accurately predict risk of developing breast cancer, doesn't ask any questions about patient history, but it's really, really accurate at predicting risk of developing breast cancer. And I think that is going to be exceedingly helpful and is fundamentally going to shift the way that we approach high risk patients. You know, I'm funny enough. Uh Chrisy, I, I was just at a breast cancer meeting three weeks ago and A I is all we're talking about because obviously see earlier, we detect breast cancer, the better outcomes we have A I as applicable to breast imaging. So, Kate and I had a conversation two weeks ago about how we, you know, integrate A I and we're gonna get those resources here at Baptist Health. So we can really provide the patients with the best technology available. But like Kate, I'm super excited about the applications of A I in breast imaging because that's the earlier we find that the better for our our patients. Absolutely. Well, um that's it for the questions. Um I just wanted to say thank you again to all those that made the time to attend. We hope this information was most useful um as stated before this is being recorded. So we are going to be able to provide you with this link. If you want to go back, use it as a resource share with other colleagues and other staff members as well as our team will be going into your office is ensuring that you do have all the tools and resources necessary to make sure your patients have their breast imaging or any imaging done with Baptist Health South Florida, Doctor Limpen team and if needed um with our breast team, uh benign breast breast cancer prevention and breast cancer team at Miami Cancer Institute. So hope everyone has a wonderful evening and again. Thank you so much. Thank you all.