114. Prioritizing Women’s Health: Screening Recommendation Updates for NPs (CE)

(upbeat music) - From the American Association of Nurse Practitioners, I'm Kami Halzer, nurse practitioner, nurse midwife, AAMP education specialist, and your host for this edition of N.P. Pulse, the Voice of the Nurse Practitioner. (upbeat music) (upbeat music) - Welcome to N.P. Pulse, AAMP's official podcast, bringing unique nurse practitioner voices and expertise on issues that matter most to N.P.'s and our patients. Nurse practitioners in a wide variety of settings are key to identification and treatment of numerous conditions affecting women of all ages. As guidelines often change, and occasionally seem to conflict, N.P.s must still be able to individualize screening, testing, and treatment recommendations for our patients using a shared decision-making approach. Horatizing women's health updates for N.P.s is a two-part series dedicated to the latest testing, treatment, and guideline updates in a variety of topics in women's health. This podcast is intended as a broad overview of those most recent changes. Please join me in welcoming women's health faculty experts, Khalil Demombrian, Lisa Chisholm, and Nancy Berman. - Wow, I am so excited. So I'm Khalil, and I'm here with my great colleagues, Lisa and Nancy, and what we intend to do this evening or this morning, or whenever you are at your leisure, and you can listen to this podcast, is to take away some pearls on clinical guidelines, clinical management, and just the ideas as you interface in the realm and the space of women's health. And so that's what our goal is, and again, this should be laid back. And we just want to have fun here, and so that's our intent, casual conversation. So I'm gonna point to my colleague, Nancy Berman, and she's gonna talk to us about a very important topic, and that would be cervical cancer screening. In women's health, there are many ideas, and many concepts about how we manage cervical cancer screening, how we screen, obviously. And so Nancy is gonna just take it away, and just give us some excellent tidbits, pearls, and content. So Nancy, how you doing today? - Well, great, thank you, Khalil. This is such an exciting topic, because there have been so many changes through the years. And we know that for women often, cervical cancer screening has really been their definition of why would I go in for an appointment. But changes are evidence-based, and we've really learned so much over the decades. And we've learned so much about HPV. We know the foundation of screening is understanding that 99% of cervical cancer is caused by human papaloma virus. We now have a test for the virus. We test for 14 high-risk or oncogenic types, and we know that the woman whose test is positive has a cervix that should be followed diligently. But there's so much education to be done because we need to help women understand, first of all, the cervical screening is just a piece of the women's health visit, and it's a very important piece, but we don't do it every year anymore. You probably have, like I, have had women who were resistant to less frequent screening, the widen screening interval. I know that that would be something you've experienced in your practice. But why have we widened the screening interval? Well, we've learned that most anyone who's been sexually active is likely has been infected by one or more types of HPV. And the good news is that the virus is usually clear to a level that is no longer detectable. So what do we mean by clearance? And that's important to educate women when we say that you've cleared HPV. Most everyone's infected, most everyone clears. Kind of the new term is that it's no longer detectable. And that's important because have you had women who have been really upset thinking that if a test is positive for HPV, that a partner must have brought something new in to the relationship? So Nancy, you know, that's perfect start to this conversation, and you really highlight the fact that there have been significant changes in cervical cancer screening. Tell us if you can. And as you participate with the writing and the development of the screening guidelines, we jump from doing a pack every year until now we have this three to five-year duration. How best do the guidelines fit? Or how best are they appropriate for the general population? Yes, let's just review the fundamental points is that again, most everyone is infected. We assume we don't take a sexual history to determine who should be screened for this HPV caused cancer. HPV is common. It's ubiquitous most everyone's infected. Most everyone clears to levels that are no longer detected. But we're using a new tone now, which is the term reactivation, that sometimes for some reason be it an immune response. There are reasons that may be unknown that a woman who's monogamous in a relationship long term suddenly, her HPV test is positive. And we need to be able to cancel that woman and say, it doesn't mean it's new, this could be decades old. It could be a very old infection that reactivated. But the important thing to know is that our HPV testing is highly, highly sensitive, less specific than a pap, but highly sensitive. And we can reassure a woman that if your HPV test is negative, we know that it's not likely minimal risk of any disease today, and that future risk is so low that we can safely do the next screen in a situation of the general population, screen, screen negative, HPV, if it's co-testing pap and HPV together, or if it's an HPV alone, which is the newer way to screen, which is called primary HPV screening. Let me just talk about that for a minute. OK, and yeah, and so what I really just as you move forward, what I really hear you hammering home and importance and significance here is that with the emergence of our ability to test for HPV, we've increased our ability to target and find out if women are at higher risk or make a more move toward a more diagnostic direction. Is that what I hear you're saying with the HPV portion of the pap's? Yeah, well, absolutely. And what our data has said is that HPV testing is actually again more sensitive, it's the more accurate test. That is what has led to primary HPV testing. Remembering that we take one sample from the cervix, put it into a liquid-based medium, and from that vial, multiple tests can be run. Co-testing was approved in 2003, which is the ability to ask at screening for both a cytology, a pap, and an HPV test. Co-testing has been around for 20 years, but I have to say, in my community, I still have people who screen providers who are still not doing co-testing. And now we're moving on to where, although approved seven or eight years ago, primary HPV screening has not really taken off yet. But I want women who are screened and the providers who screen them to understand that the cytology does not add a lot, that what we have with the liquid-based vial is the ability to reflex to a pap if we do a primary HPV. So just to clarify, right now, most practitioners are asking for a pap in an HPV test. But what is already the standard of care in Europe in Australia is asking for just an HPV test. If it's negative, correct guidelines, say, we should repeat in five years. If it's positive, then from that liquid-based vial, a pap can be done, a slide made, saying, well, the virus is there, and have the cells become abnormal because it is in the cells. So just remember in terms of natural history, it is the persistence of HPV over time that can lead to neoplastic change and progression over time to pre-cancer and on to invasive cancer. And the whole point of screening is to find pre-cancer and treat it in thus preventing cervical cancers, the cerebral cancer is a preventable cancer. So just back to understanding, HPV testing is available. In co-testing, we actually have five FDA-approved tests on the market, but primary HPV testing, we only have two, and that's the co-boss and on clarity. And those two tests do give us genotyping every test of HPV 16 and 18. The biggest difference in when we start screening is the newest American Cancer Society guidelines have stated that we should begin at age 25, but the ASCCP and the American College of Obstetricians and thenicologists have still supported starting at age 21. Papalone is less sensitive, less accurate, has to be repeated every three years. Co-testing if half in HPV negative is every five, in HPV primary, HPV only is every five as well. But I really want to also address risk-based management. And this is the newest thing to know. Risk-based management means that we don't have to think about what should we do in a clinical situation for most of the results that we get. We have an app available on both Android and Nunduffle phone and we have availability on the website of ASCCP. - Wow Nancy, I think you made a good point here. And I think for the average listener, we're hearing about this HPV and we're understanding again the significance and the power of testing for HPV. But you hit on something that I'd really like for the listeners to hear. And that was, you mentioned the HPV-16 HPV-18. Can you tell us a little more about what does that mean to the average clinician? And why should we pay attention to the difference? - We ask, will HPV-16 and 18 cause 70% of cervical cancer? And they're really quite common. And what we know about is that it is the persistence of HPV-16 in most squamous cell cancers of the cervix and HPV-18 in those glandular lesions or adenocarcinomas. But it's a much higher risk and for that reason, it's helpful for us to know if our patient has HPV-16 or 18. And that's why when we look at primary HPV screening, knowing whether 16 or 18 is present, helps us stratify that woman's risk. If they were HPV positive, when only an HPV was ordered in the lab, they will reflect to a path and we'll have that information. And what we're able to do now and the apps that we have available to us is plug in as much information as we have. What we've learned through data is that past results influence the current risk of CIN-3 plus or pre-cancer. And a woman who is HPV negative and path negatives on her previous screen in current rehearsed positive findings has a different risk than the woman who had HPV three or five years ago. So what we do with our new risk-based management is plug in everything we have. And it gives us a strategy of management based on the current risk of having pre-cancer. Many of you may say, oh no, new guidelines again. Why do we keep getting new guidelines? But the beauty of the new ASCCP risk-based management guidelines is that they are enduring. Enduring means that we will never have to get new guidelines and as new technology becomes available, those new options are being put into the algorithms. Currently there is an enduring guideline committee. And the newest things that have been looked at in terms of huge amounts of data, you know, mostly collected at Kaiser Permanente Northern California where it's a captured population. The first thing I would want our listeners to know about is dual stain. And dual stain is a way that cells can be evaluated for the presence of two biomarkers, P16 and PI67. And when these signals are positive, it suggests that there is a transforming HPV infection and that that woman needs further evaluation. So just as dual stain right now is being seen as something to incorporate into guidelines after evaluation and vote, that we won't start over with new guidelines, but if we have dual stain available, we'll be put in. I just wanted to mention also, other than dual stain, we'll have expanded genome typing because we have two tests that allow for more types of HPV. And that will also help. But the newest exciting is that the FDA has approved two different tests for self sampling for HPV. - That's pretty exciting. - Now it's exciting that we will be able to bring more screening to women and underserved situations, women who are not comfortable to have an invasive evaluation with a speculum and self collection. And these are vaginal cells. And the data is very strong in how sensitive this test is. The difference though is it's a vaginal specimen. And so there is no ability to reflex to cytology after a positive test or a dual stain, which again is a slide made of cells. So we have these three new technologies as a great example of how these will be incorporated into risk-based management rather than starting over. - Great. So Nancy, can you tell me more about this app or is that something you were gonna share later? - Well, as far as the app goes, it would send our listeners to the ASCCP website. The beauty of the app is that we pick the clinical scenario which is whether it's routine screening or follow-up after colposcopy or follow-up after an abnormal app or HPV, it's all laid out. We pick the age of the patient. We plug in as much as we have. We put in and it calculates for us what the percentage risk of having pre-cancer today is in what is the management, whether it's immediate colposcopy or in the highest risk patient, the woman who's HPV positive for 16 or 18 and has a high grade abnormal path. Those will then have now recommendation for what's called expedited treatment. It's like the skip colposcopy and biopsy, their risk of high grade pre-cancer is so high that expedited treatment is recommended. And the app does it all, we don't have to calculate, we don't have to do anything special. But it's really important to know that risk-based management is there for us. We get results and we need to know what to do with those results. So I just wanna say in terms of this topic, I just wanna just sort of summarize by saying, be aware that we need to screen. This is a preventable cancer. A cervical cancer is preventable. We don't take a sexual history to determine who should be screened or when or how often, that we follow the guidelines and the guidelines are based on very, very large amounts of data. Then when we get results, we reassure women of what it means. We follow abnormal with risk-based management and make sure and keep up that these new technologies are coming. We have FDA approval for the two new self sampling, self-collection kits. And we'll have to see how that plays out, who pays for it, how do we follow it up and so on. But it's an excellent test. So right now, papalone can still be done, but it's not as accurate as HPV testing has to be done more often every three years. Cotesting pap and HPV, you're fine if you still cotest. That's your choice in the negative HPV repeating five years. But primary HPV be aware that this is the recommendation by American Cancer Society, which is you only ask for HPV. And if it's negative, repeat in five years, if it's positive, then all tests are then reflex to a pap. Just in closing on this topic is based on data. Currently, our guidelines also tell us that at age 65, we can exit women from screening for good. If there's been adequate screening, which is defined clearly as either three pap tests alone, two rounds of pap and HPV cotesting in the previous decade and no way of normal. And it's important though that there has been screening. I love the patient who comes in and hasn't been screened in many, many years. And I explained to her that the best thing I can do is an HPV test. And the problem is also as women age, that Medicare doesn't pay for HPV testing in screening after 65. But I have many women agreed to pay out a packet. When I take that time to explain why an HPV test is the best thing we can do when she has been inadequately screened for many years. So also taking the time to explain to women who don't have a cervix after his directory, there's no need to screen the vagina. But as you know, many women think that or don't know even what the cervix is, let alone whether they still have one after his to me. So you read my mind on that question. We really need to make sure that a woman who has had his directory that it was a super cervical with a cervix left behind that should be screened according to guidelines. And then one last thing is just that we have an underserved community of trans men who may have a cervix and are not being screened due to difficult access due to hormonal or lack of hormone to reaching the vagina and being able to reach a cervix or because of discomfort in seeing the practitioner before this care. So that's a real important area as well. Education of trans men to receive appropriate screening. - You've given us a lot to think about. You've given us some excellent data, some excellent direction and hopefully our listeners will be able to take some of this information and incorporate it into their practice and incorporate it into their education when they're not performing the path but why we don't perform a path. Why you don't need it right now? What are we looking for? The there's gonna be two potential results in HPV and a cytology result. So excellent overview and thank you. - Fantastic, wow, that was a lot of great information. While I have your attention, Nancy, and while you have the stage, we're gonna change direction here and although we're still talking about women's health and screening, we're gonna talk more about, let's talk about bone health. And so we know later in life, many women are at risk for osteoporosis and you know, just issues with bone health. So let's kinda lay the landscape of where we are in regard to screening what the current recommendations for our supplementations are, whether it be vitamin D, calcium, exercise. Let's talk a little bit about bone health. - I'm excited to talk about bone health. What an area where we can make such a difference. In general, there's under screening for increased risk for fracture. And there's lots that's happened that's new. I've been in practice for so long. It's wonderful to have historic perspective. You know, 25 years ago, we didn't even have bone-dance atometry a way to diagnose low bone mass, let alone effective treatment. And in terms of what's new, I think it's really important to know that we need to find men and women at risk for fracture. Because we know that a first fracture begins a second fracture. The risk of subsequent fracture goes way up. And what we've learned is that there's a whole new idea of sequencing drugs. And so we now have guidelines that tell us that there are women who are at high risk for fracture and women at very high risk. And so kind of backing up, who should be screened? The Endocrine Society and the US Preventative Task Force agree as well as the menopause society. There's pretty much an overlap that all women should be screened at age 65 with bone-dance atometry. But women with risk factors may need screening sooner. And those risk factors include low body mass index women on steroids. Interestingly enough, diabetes is a risk for bone loss. I mean, just being postmenopausal with decreased estrogen is a risk for bone loss. But we do a bone density test. And we get what are called t-scores. When the bone is compared to that of a young adult average, the change or the difference in standard deviations creates a score. I love showing my patients the continuum of t-score from normal through wild lots, moderate to a diagnosis of osteoporosis. And what's always fun is I have so many patients who ask me, oh, which hip was the one that was worse? Because I know what they're thinking, you know, on having hip pain. And that's where it's really helpful to explain that this is about the inside architecture of the bone. Anything they're feeling is where bone meets bone at joint. As women age, they get degenerative arthritic change at the hip. But important to explain is we don't feel a thinned out bone. So that's why we have to do the test. And where we have done a silent problem that we have to convince somebody, a woman, to take medication for something that it may seem like to have you dealt with patients who've heard on in the media, how bad those medications are. And my dentist thinks it's bad. So we have to really dispel a lot of the myth and the concern, essentially, where identifying women at risk, where it's either high risk or very high risk and then finding an appropriate plan of management. OK, OK, so that's a good segue into, you know, kind of having this beginning conversation about screening. You have a patient in front of you. She's 65 or as you've alluded to, maybe you need to screen sooner. How does that maybe in terms of, is there any particular demographic, racial demographic that may benefit from earlier screening or is the data showing is this just straights 65 across all women or is there any populations or pockets that are being looked at differently? And what are your thoughts of that direction? Or what is the science telling us in terms of osteoporosis screening of that direction? Well, I think we need to look at the fact that yes, all women at 65 should be screened. But body type, we know that estrogen is produced peripherally and fat. And so that's why I explained to women that when the ovaries are quiet and no longer making estrogen, there's a rapid loss of bone. There's a rapid acceleration in the first couple years after the final period, and it does slow down. But we can't assume racial difference or body type differences. We can't assume. Because as I said, diabetes is a significant risk factor. We know there's been some question of, the whole world has gurred acid reflux and whether these progenpub inhibitors may inhibit calcium absorption. We know that African-American women may run long-vitamin D levels and that we also don't always know what is a vitamin D level tell us? Is there some question about a steady state in the bloodstream? But we do know that vitamin D is essential for calcium absorption. We do need to be aware that there are secondary causes of osteoporosis, including things like hyperperperthyroidism. But hyperperthyroidism can also be secondary to vitamin D deficiency. We need to be sure to know that smoking is a huge risk for bone loss. But once we do a bone density, we identify the woman who should have screening. Once we get that information also to know that there are four ways we diagnose osteoporosis. Anyone who's had a vertebral or hip fracture, that is osteoporosis regardless of the bone density. Anyone who's had a fragility fracture of the humorous, the distal forearm, or the pelvis with mild or moderate osteopenia should be treated. That's osteoporosis. And I've mentioned T-scores. When a T-score at any site is minus 2.5 or lower. But the next thing I want to really tell our listeners is, if you stop at that, there's a fourth way we diagnose osteoporosis. And that's the use of the frags 10-year fracture risk calculation. That sounds like another app. It was going to ask you, what do we have at the point of care? Is that where you're taking this right now? Absolutely. And the frags 10-year risk calculation is really easy to do. I do it all the time because I have a diagnostics center that does it for me. But we know that data in is data out. What I'm finding is one of the questions-- so what fraxias is came out of the University of Sheffield. And it's based on a data set. And what we plug in is age, height, weight, whether male, female. And it defaults to a negative, a no, to a number of questions, including current smoking, whether a parent fractured a hip, whether there's a fracture history as an adult. The machine used the actual bone density. And there is a button, and it calculates a 10-year risk. And what? Yeah, I mean, it's so easy. But if I have patients who at the diagnostic center answered yes to a fracture history, but it was a foot fracture. And a foot fracture is more not fragility fractures. So that's why I would recalculate even though-- because it may make the difference between whether somebody needs treatment or not. Age is a huge part of fracture risk. And I show patients every year to get older fracture risk goes up. But what I'm telling our listeners is, you may be familiar with the bone density test and t-scores, but be sure you're familiar with fractures. And fractures, you can just go to the University of Shelby. I put-- you just search "frax calculator." And it opens, and you populate those demographics, and it defaults to a no on all the questions. And you just change to yes if there is a positive history. Is this a website, or is it a-- Yeah, it's a website. OK, OK. And it is really easy to do. And what changed-- again, we're talking about what's new in this podcast. What's new is that fractures was considered a recommendation for prevention treatment in the past, but in the newest endocrinology guidelines, it became a diagnosis. And a recommendation that treatment should be initiated. And I just want to do a real brief overview. How do we decide on treatment? And the newest thing in osteoporosis management is sequencing, which is, when a patient is at very high risk, which is on the continuum of t-scores, minus 2.5, is osteoporosis minus 3 and lower, is very high risk. On the fracks, at the hip, 3% to 4.5% is high risk for fracture, but greater than 4.5% is very high risk. So now, the newest thing for us to know is once we've identified those patients at very high risk, we need to consider whether they are a candidate for anabolic bone-building therapy. That therapy-- No, that was a mouthful. The week has three agents that are pharmacologic agents for bone-building. Given 18 months, 24 months, and one year, those medications are short-term, which do other anabolic. They put new bone in, but they must be followed with maintenance on an anti-resourced evasion. And it's a lot of fun in teaching, which we like to do with our patients. That bone is living tissue cells are put in, and cells are taken out. And the problem is, when more is going out, then going in, the net effect is a thinned out bone at risk for fracture. And I show patients and say, most of our initial therapies reduce how much bone goes out. They're anti-resourctive. But the new guideline, as I said, is-- but we need to identify those women at very high risk would benefit by a much more aggressive bone-building treatment first. So I'm the typical primary care provider. And in my own practice, I obviously see 100% women sitting at my desk and I have the ability to actually have my patient look at the computer with me. I met my Fracks score calculator, or-- but I've done my basic Fracks scoring. I've actually ordered my DEXO or my diagnostic intervention. And now we have the results at. And the question I'm really asking is this something as the primary care provider ship this being, particularly, in my realm, or basic skill set, because I provide care to women, or is this for a high level intervention? And most of these folks we refer out. What do you usually do? I love the question very much, because we all have to know our level of competence in all that we do. And I think just as an example, for me, I have done anti-resourctive therapy, which includes this phosphonate, which includes denossumab, a rank ligand inhibitor. I had done those treatments for years, but I identified an under-pronology practice where I could send those patients that I deemed very high risk who would be candidates for anabolic therapy. I then reached a point about a year and a half ago where I realized that the weight to get in was long, and I decided with a lot of education and consulting to take it on myself. So I am now actually prescribing that bone building in anabolic therapy, but it took me 20 some years of nervous cirrhosis. So my recommendation is I think every practitioner needs to understand what is the appropriate treatment, and have a referral option. And say, I believe this patient would really benefit by the lower aggressive short-term therapy first. OK, the sequencing is really means that the data says it's better to use it first, followed by anti-resourctive therapy. That's a good tip, too. And I think most of us inherently would like to be able to manage our cohort of patients. We've established a base with them. We see them for their primary care. And if there are some diagnostic interventions or treatment modalities that we can keep at home and offer them, I think that enhances the primary care provider relationships. But then you write, I also see where there's that necessity when there's a different skill set required, and obviously the opportunity to refer to the endocrinologist. But as a primary provider of care to women or specialty care to women, it is important to know the basics and the foundation and what's a workup for secondary osteoporosis that when women have had surgeries in their lumbar spine with instrumentation or with hardware, we don't generally look at those vertebrae and we look at an additional site of forearm. Well, the little pearl is when the forearm, and you will see this, I've seen a minus 3.4 of very low t-score in the forearm, and a pretty minimal loss at the hip. And that's a tip off to think about hyperperthyroidism. I mean, there's little things that we all pick up through experience. But I will say it's such a great part of our field, this whole bone area, because there's so much education. We have so much in the media, the myths about-- do you remember when it came out in the media about a typical sub-trochanteric fractures of the femur? This fascinates the process of the jaw. The newspapers had headlines about women stopping their osteoporosis medication. We have to do a lot of risk-benefit discussion because a lot of women have said, well, I don't want to take that. I heard from my neighbor, my sister, that it's really bad. I heard from my dentist, you know, osteoporosis of the jaw is a very rare complication of this phosphonate, and actually all osteoporosis drugs. It's very rare. But I ask every patient, are you having any upcoming tooth extraction or tooth implant? Because I would defer starting a medication until the jawbone had healed. O-N-J, osteoporosis of the jaw, it's very rare. But the person who has that complication doesn't care how rare it is. But understanding, for example, that the half-life of this phosphonate can be a decade or more. So we get confusion because patients may be told by a dentist to hold their medication because of a tooth being pulled. Whereas it probably, it really doesn't do anything. We have this drug integrated into the bone matrix. And it's there. But there's nuances that we learn along the way. But I think the main thing in really closing on this topic is to say that this is a great area for nurse practitioners. There's a great amount of education. And we know that screening is really under-performed. And we know that fracture prevention is really important. Hip fracture can often be the disaster that takes somebody from being active mobile to disabled or even deaf. Yeah, no, you're right, you're right. And so what you're really speaking to is the impact on the quality of life. I have a quick question, though, because we kind of see this a lot, or we have people ask us a lot. And that's pretty much the utilization or the screening for a vitamin D. We have different camps out there. How often do you assess for vitamin D? I think that just understanding that true vitamin D deficiency is under 20. And that lab normals range a little bit, mostly over 30. But what is important is the patient on medication, in particular on denossumab, or one of the bone building antibiotic agents, that it's really important for the patient to take calcium supplement in vitamin D. There is a risk of high fluke. Check them together on those agents. But the general patients we're seeing, I know there's been controversy. I do check vitamin D levels, not often, but I think that it's reasonable to do. And as I said, because a very low D can lead to a secondary hyperparathyroidism, because we know it's important for calcium absorption. And that, especially based on where you live, I live in a place that doesn't have sun all year long. And so we know that most vitamin D is from synthesis and the skin, from the sun. Yeah, now you do know that the trait is the best place on the planet to write. We're once-- so I would have said, I didn't mention being here in Michigan. Our sun is lacking much of the year. But so yeah, I think that it's helpful for educating patients. I do check vitamin D levels. As I said earlier, there was some debate at one point about whether there was a study state, what the level really means when you draw it. It's expensive. We do a lot of testing that is very expensive. But I think it also helps. I do find lots of women who have deficiency. And within the recent guidelines suggest that there's not many times you need to do a prescription 50,000 international units of vitamin D. Most of our patients can use over the counter. One or 2,000 international units is a good maintenance dose. OK, thanks. And as always, Nancy, you're just a wealth of knowledge. And thank you for sharing the tidbits and some guidance for us in the area of osteoporosis and vitamin D bone health for our women. Thank you much. Just such a fantastic conversation. Again, I'm Khalil de Mambrian. I'm here with Lisa Chism, Nancy Berman. We're just sitting around talking about women's health. I know we're passionate about taking care of women. And so we're going to switch gears a little bit. We've been hearing a lot from Nancy. And she's been sharing her wisdom and her pearls. And now we're going to let Lisa give us some tidbits and some pearls and some insight. And we'll start out with breast health. So Lisa, how are you doing well? I am doing well, Khalil. How are you? I am doing well. I think one of the-- I just was subtly reminded that we're all from Detroit. So we have to put a bid in for the Lions Dig rate this year, Michigan won the National Championships. So as we continue on with our podcast, that's our little I guess, my little pun for Michigan. And so we're going to talk about breast health and screening guidelines. And so, Lisa, the floor is all yours. Or shall we say the Mike's all yours? Well, thank you, Khalil. So it's a pleasure to talk about one of my favorite topics that I'm extremely passionate about. I've been immersed in breast health for probably the last 15 years of my 30-some-year careers in nurse practitioner and very passionate about breast health. Despite breast health being one of the areas that we have some of the best screening for, there's still a lot of myth. It's still as echo Nancy's words that this is another area where nurse practitioners can really make a difference because of the lack of education about breast health and breast screening. I think something that we need to continue to spread awareness is that breast cancer remains the second leading cause of death for women in the United States. Wow. It's a very treatable cancer when caught early, which is why screening is so important. If we're going to talk about some updates, if we're talking about major societies, American College of Radiology, Society of Breast Dimminging, American Society of Breast Surgeons, ACAD, NCCN, National Comprehensive Cancer Network Guidelines, the organization that most recently had the biggest change in their guidelines was USPST up about a year ago, this May, eventually came on board and said that screening should begin with mammogram for average risk at the age of 40. So now we have all major societies and organizations in agreement that we start screening for average risk women at the age of 40. Yeah, that's a big deal. USPSS was at 50 and we estimated we probably missed about 6,500 cancers a year with that. So the fact that all societies and organizations now say age 40 was a big step. USPSTF still now does say every other year. However, many of us who do this work do follow American College of Radiology, Society of Breast Imaging, ACAD Guidelines, which are starting at the age of 40 and every year. But I think something that I spend a lot of my time educating folks about is that age 40 is for average risk. So another guideline that has been adopted American Society of Breast Surgeons is that we now screen women at age 30 and up every year for their individual risk calculation of their risk for breast cancer. And there's a couple of different tools that can be used. There's the tire cusic, clouts, the gale model, but in the literature, the one that's most reflected when looking at which we should use to determine who should start screening early and what that screening should look like is the tire cusic model. And I'll tell that you mentioned that, at least to help us understand why tire cusic is so significant and why we need to really pay attention to. Well, it has been determined in the literature to be the model of choice when determining supplemental imaging. And when I talk about supplemental imaging, what I'm referring to is what we do beyond the mammogram. So if we're starting average risk women at the age of 40, if we're capturing women who are above average risk, intermediate risk, or high risk, which is defined by a 20% or greater lifetime risk of developing breast cancer, that would be our high risk folks. And even intermediate, 15 to 19% were paying attention to, and anyone above average. So say 40 years old, not many risk factors, average risk for breast cancer might be around 10, 11% in your lifetime. So for folks who are higher than that, that we may be capturing in their 30s, leading up to their 40s, we're now suggesting we start screening sooner. Is that a tire cusic score of 20% higher? Is that what you're saying? On front or greener, yes, yes. So basically, that's the model that's used most frequently when looking at starting screening and supplemental imaging, whereas the mouse model really reflects a much more in-depth pedigree and family history, and sometimes you'll find your genetic counselors looking more at the mouse, where we're looking much more in-depth at second, third, fourth degree relatives. The tire cusic is looking at first and second degree. It's not that we don't care about beyond first and second degree, but if we're talking specifically about which models are used more frequently and more reflected in the literature, and most importantly, are reflected in our guidelines that are helping us understand who should start screening earlier and what does screening look like, what does supplemental imaging look like? And when we talk about supplemental imaging, we're really also talking about breast density, which if I had to mention two areas of breast health that have, I think, the most advancement in what we now understand, it's that we're moving towards a risk-based screening, which I love Nancy Mendes. - So kind of like the pups here. - Exactly, that's exactly where breast screening has moved to is a risk-based screening. So if we're checking folks for where they're falling as far as their risk, and we're starting at age 30, we're hoping to capture folks who are above average risk, intermediate risk, or even high risk, to one, start their screening sooner, and two, look at what else do we need to do for supplemental imaging? For example, if your risk for breast cancer is 20% or greater, then it's indicated by our evidence-based guidelines that we also do an MRI at the six-month interval. Interval testing has been shown to be the most effective at picking up what we call interval cancers that we may be missing on mammogram A because of density or B, because it developed over the interval between mammogram, which is still going to be annual. So breast density is also something that gets calculated in the tire-cruzic model, which is another reason why that model is one of the models of choice and reflected in the literature, because it is one of the models that takes into account breast density. And we now understand that women with denser breast tissue have a four to six-time greater risk for breast cancer than those with fatty breast tissue. And density matters to us for two reasons. One, denser breast tissue is what I call busier tissue. It's stromal epithelial tissue, but it happens to produce more things. So benign, like cysts or fibroidnomas, but we also see more breast cancer in that denser breast tissue. And the other reason we care is it can obscure, it's white when we're looking at the mammogram, the dense tissue is white, and it can obscure what we can see. So three-dimensional imaging, which is standard now across all levels of density American College of Radiology, has deemed that even folks with fatty or tissue benefit from three-dimensional imaging. So it is standard of care. Can capture more with denser breast tissue, but when women have extremely dense breast tissue, it becomes very difficult to have a high degree of sensitivity with mammogram. Mammogram can reduce to about 60% sensitivity with extremely dense breast tissue. So another reason we're counseling women about their density and their supplemental imaging is, one, if your risk for breast cancer, regardless of density is 20% or greater, MRI is indicated. At interval testing along with annual mammogram. But if you are not at elevated risk, but you have denser breast tissue, that's when we're having an even richer conversation about what other supplemental imaging would you benefit from? You can really all breast ultrasound, yeah. - One of the questions I think that the average listener is gonna have is you jump to MRI as a modality for further assessment. And as you know, we're all mostly challenged with cost of our interventions and our modalities. So one would quickly say, well, I can't get that pay for, how do you get that pay for? And you're talking about these adjunct modalities. And I guess I kind of heard you say genetic counseling is in there. So now that's another modality or another intervention that I have to refer her out to. Are these things cost heavy or are there deterrents? Obviously other than the cost that will impact the helping to make this decision on these greater than 20% women when you're trying to get them further care? What do you see? - Well, first of all, if your risk for breast cancer is 20% or greater, then because it is evidence-based guideline that women be offered an MRI, then it is approved. So a prior authorization does go through, but it's approved as long as the risk for breast cancer has been recorded as 20% or greater. So it should be approved. Now, how much is out of pocket can be challenging depending on deductibles or displays? I have conversations with women about this all the time and talk about something called a rapid MRI, which is a 15-minute short sequence MRI that based on the data is sufficient for screening compared to a standard protocol MRI. And although you do have to seek out what imaging centers offer this in your area, I have an imaging center in my area that I will send folks to, and this particular modality is a $400 charge out of pocket. It isn't run through insurance, but for some of my patients who have high copay, high deductible, or one in MRI because they are dense and intermediate risk, which the American College of Radiology has a couple of papers out in the last 2022-2023 literature showing that even at intermediate risk, MRI is going to be more sensitive with dense breast tissue than whole breast ultrasound. So for those folks who either want an MRI because they're dense, or are 20% or greater and have a higher copay or deductible, that's when I turn to the rapid MRI and make sure folks are aware of that, and we can send for that as well, 'cause it will be sufficient for screening. Oh great, are you using the Diagnostic Code C15.01 as that elevated risk, or what, like how are you coding for that? - Yeah, and I don't honestly know the code off the top of my head, but increased risk for breast cancer does have an ICD-10 code. - And that's Z15.01. And actually, in my practice, I use that, I sent out a letter whenever I see a tire of crucic that's elevated. We talk about genetic counseling. I can imagine other folks having potential challenges at getting that patient pointing the right direction. I'm glad you kind of brought that up very quickly in this talk. - Well, dense breast tissue also has a code. So when we're doing a whole breast ultrasound, which isn't always covered either. It's run through the insurance, but sometimes there's a partial out of pocket cost. In our center, it's about a $350 test, but we do code for dense breast tissue to sometimes get that covered for the patient and it's getting better, coverages improving. The important thing to understand about whole breast ultrasound is it's nowhere near as sensitive as an MRI. So that's why our current guidelines and the literature are reflecting that 20% or greater is the supplemental screening that's recommended with mammogram for folks who are 20% or greater. And even intermediate, they're looking in the literature now at perhaps recommending MRI as well. Because whole breast ultrasound picks up about two to three cancers per 1,000 negative mammograms with extremely dense breast tissue where MRI picks up anywhere between 16 and 22 for 1,000 depending on the paper that you look at. So there's a significant difference with sensitivity and when we're talking about dense or breast tissue, I love it that there was a celebrity. I think Olivia Munn is her name and she actually went on Instagram and talked about her diagnosis of bilateral breast cancer that was found because someone did a risk assessment. She was found to be in her theories as far as a risk assessment and her provider offered her an MRI which led to early diagnosis of bilateral breast cancer. So mammogram, while mammogram is gold standard, reduces mortality by 40 to 60%. And there is some things we can only see on mammogram such as calcifications, asymmetries, but when we're talking about folks at higher risk, who we know have higher risk for breast cancer, who have dense breast tissue, regardless of density, the 20% or greater the recommendation is still going to be interval testing with MRI. But if folks are more have dense or breast tissue, either heterogeneously dense, which basically is 70 to 75% of the tissue's dense or very dense, all the tissue's dense, then we know that supplemental imaging does have a role in increasing detection of breast cancer. - Oh wow, wow, this is great, this is great. 90 R92.3 is that actually ICD-10 for this breast tissue, for those who are listeners that may want to kind of jot that down in their mind. - Whole breast ultrasound has its limitations with sensitivity, although it does have somewhat more access for some folks than MRI. So sometimes what I'll tell folks, if you're dense and higher risk, I care that you do something rather than nothing in addition to mammogram annually. Nothing's going to replace that. Other modalities that are not yet approved for screening include contrast enhanced mammography, which is an X-ray using contrast. I think that that coming up in the horizon may really increase detection or denser breast tissue and also give you the benefit of mammography, where mammography again, the only way we can see calcifications or asymmetries. Molecular breast imaging, I've seen coming go somewhat. It is out there as a modality for screening, but the difficulty with that is you can't actually get a biopsy from molecular breast imaging. So there are some downsides to that. And contrast enhanced mammography is available in some institutions and in some centers, but I do think coverage for that is going to be limited and challenging because I don't think they've actually hit guidelines yet. If we're gonna talk about what's actually hit guidelines, we really just have mammography as our standard of peer for screening and insurance to my knowledge is required to cover a screening mammogram annually for women and then MRI for folks who are high risk or intermediate risk with denser breast tissue who wanna have an MRI, hopefully having more access to rapid MRI if cost is an issue even with copane deductibles, but if your risk for breast cancer is 20% or greater than MRI is standard of peer and guideline along with annual mammogram. I think beyond that, nothing else really has the data or the evidence-based guidelines to support just yet. - Okay, yeah, that helps me a lot. Which one out of these increasing modalities or have you heard may make the experience of receiving a mammogram or a pleasant or, which one hurts the least? - Mammogram is gonna be gold standard and I tell women it's 10 minutes. It's two views each breast, four views each breast if you have implants, which a lot of women do. Still highly effective screening modality within plants. There are guidelines and techniques that are supported by the evidence to not cause harm to the implant 'cause sometimes women are worried about that as well. There is some compression, but with three-dimensional imaging which is standard of care, there is slightly less compression now, but such a highly effective screening modality. When you think about we have the evidence to reduce mortality by 40 to 60%, because we are detecting breast cancer at stage zero, stage one, before anything is palpable. Breast cancer has to be, a tumor has to be about a centimeter and a half, generally before it's actually palpable, and sometimes that can be anywhere from 18 to 22 months that something has been present. And when we're talking about labular breast cancer, frequently those breast cancers, the ones that scare me the most, we don't feel because they act more like finger projections in the labular tissue of the breast and they are much harder to see on mammogram because dense breast tissue can hide those types of cancers, which is why we're continuing to have robust conversations with women about density, making sure they understand why it matters, what screening techniques and modalities are available, what's evidence-based, and what their individual risk for breast cancer is so that we can do true risk-based screening for breast cancer. - You've already given us so much great content to think about and such ideas to think about. And so we're sitting there, we're at that point of contact with the patient, we're having this dialogue, whether it be, hey, it's time to start screening. Let's back up just a little bit. And if we could walk through a really comprehensive check of who's sitting before us, what is the risk assessment? What's important, we don't want to miss anything. If we could give our listeners some caveats and some tips and some ripple acts, I guess, in terms of risk assessment, can you share some of that information with us, Lisa? - Absolutely. So the tire cruiser, you can actually pull up, I pull it up on my laptop that I have in the room with the patient and I run it right in front of them and ask them the questions, which serves two purposes. One, we're performing the screening and the risk assessment. And two, women learn what their risk factors are or what risk factors in general are. And I usually split risk factors up to non-modifiable and modifiable. So first of all, when you mention genetic testing, the general guidelines are that if a woman has a first or second degree family member under the age of 50 with a diagnosis of breast cancer, they meet the criteria or a first or second degree family member with a history of a barian cancer, they meet criteria or Ashkenazzy Jewish heritage, are generally some of the guidelines for who's eligible for genetic testing. And women also need to understand that only about five to 10% of breast cancer is related to a genetic mutation. So when we're talking about non-modifiable, genetic mutation is one of them. Age of menarchy, you can't modify when you have your first menstrual period. So generally speaking, 11 or under is a risk factor. When you experience menopause of your final menstrual period, generally over 55 is a risk factor. Family history, as we mentioned, breast density, high-risk pathology. So in other words, if you've had a breast biopsy and you actually have atypical cells, either atypical ductile hyperplasia, atypical labular hyperplasia, labular carcinoma incite you, these are high-risk lesions while they are not actual breast cancer lesions. They present an elevated risk. They won't turn into cancer, but sometimes we find cancer cells with these lesions. And if we don't, the awareness that these lesions developed give us the awareness that you have a higher risk of developing more abnormalities such as breast cancer. Another risk is someone who's had chest wall radiation under the age of 30. So folks who've had maybe Hodgkin's or non-Hodgkin's lymphoma in their teens, these folks have specific guidelines for screening. We actually start screening with MRI for these folks at age 25 and MRI and mammogram at age 30, because they have such a significantly higher risk for breast cancer. Some of the more modifiable risk factors are age of parity. If you have your first baby under the age of 30, your lower risk, over the age of 30, you have higher risk. And that has to do with what happens to the breast tissue with childbirth. When women have a baby, their breast tissue changes and becomes much more sensitive to estrogen. But then over time, the breast tissue remodels and becomes less sensitive to estrogen. So the thought behind that is if you have your first baby under the age of 30, you've reduced your risk by the breast tissue becoming less sensitive to estrogen. And this is primarily estrogen positive or estrogen receptor positive breast cancer, which is about 75% of breast cancers. So that's a somewhat modifiable, maybe non-modifiable risk factor. Another modifiable risk factor is alcohol intake. We know that alcohol increases your risk for breast cancer. Generally speaking, wine, it has the highest risk followed by beer and then spirits low. - Wow. You don't know how much alcohol it really depends on what you read. But generally, the most current literature reflects about four drinks a week. So unfortunately, a lot of us don't want to hear that, but that reality, that there is the connection. As far as BMI, a higher BMI can increase risk over menopause, whereas mid-body adiposity pre-menopausal can increase risk for breast cancer. Smoking increases risk pre-menopausally, especially women who start smoking at a young age. We didn't use to think that smoking had anything to do with risk for breast cancer. And then interestingly too, our folks who are on off-shifts has to do with melatonin. - Oh wow. - And he comes. And so folks on off-shifts are at higher risk for breast. - And they call them that, yeah. - Yeah, there's some risk factors that are modifiable. Rest feeding can reduce your risk for breast cancer by about 4% if you breastfeed for an entire year. And that's for estrogen positive and estrogen negative breast cancer. - Okay, let me jump in here, Lisa. You've given us a good, a nice summary of risks. I'd be remiss if I didn't highlight that, or Lisa asks you, what about that individual that's had multiple biops? - It is a risk factor, it's in the gale model and it's also in the tire-cruisic model, depending on the pathology. So if it is a high risk lesion carries much higher risk, fiber adenoma is debated in the literature as to whether or not it increases risk for breast cancer. Theoretically, fiber adenomas are benign and they are grown out. They grow out of stromal epithelial tissue, which is that denser breast tissue. They are common in child-bearing years and we really don't know why some women develop fiber adenomas. We biopsy them now, if they have any irregular features, sometimes if they're greater than two centimeters to rule out a sub-type of fiber adenoma called Volody's tumors, which can grow very quickly and do get removed. I do think that the trend in the literature and in the ACR guidelines for biopsy what appears to be benign has changed significantly. So folks that perhaps had a biopsy younger wouldn't necessarily need one if that type of finding was found now. It is a risk factor, but it kind of has to be taken in the context of what the pathology was. So while it will be measured as a risk factor in the tire cruzic and it is debated in the literature whether or not it should be a risk factor if the findings were benign because sometimes biopsies are done when they shouldn't be done and about 80% of biopsies are benign. So it is something you take on as an individual looking at the patient as an individual as to what the pathology was. But if they were multiple multiplicity and bilaterality equals benignity. So if they've had multiple bilateral fiber-- - I like how you did that. - Yeah. If you've had multiple bilateral fiber adenomas or findings that were benign, it does tend to lend that they're gonna continue to not necessarily have an increased risk for breast cancer. Fiber adenoma specifically in the literature some papers say increases risk because it reflects growth of tissue simply because it reflects busy tissue as I call it. And sometimes in the literature, they're saying no, not any risk increased risk for breast cancer because of fiber adenoma. So that's kind of my takeaway that I try and help folks understand about fiber adenoma. - Yeah, no, I think that's great. I think that's good because like I said, we all have that patient or patients that have had those multiple biopsies there. You know, there's some fear there. Some, you know, some angst, some anxiety. And so I think that's that's good. Good information. Please say as we come to the conclusion or the summary of breast cancer screening, breast cancer awareness, breast health, any other good salient tips that you'd like to offer the blisters or anything that like pearls or wisdom as we continue on with the, as you know, talking about breast health. Well, I think it would be reducing myth. I have folks who still are concerned about radiation exposure with mammogram and what we know is there's no data to date that that has caused a problem for women, that it's equivalent to about seven weeks exposure to the outside environment or 13,000 feet in a plane from both either the plane or the environment. So when your patients are concerned about radiation, help them understand that it really is okay for them to get an annual mammogram. Also, I think just reaffirming, paying attention to breast density and taking the time to have those conversations and educating women about density, why it matters and an individual risk assessment on everyone over the age of 30. Great, great. Thank you so much, Lisa. (upbeat music) To plan CE credit for today's accredited podcast, log in to AANP CE Center at AANP.org, Backslife CE Center, and add this activity with the Participation Code, W-H-U-P-D-A-T-E-1 and complete the post-testine evaluation. As always, we thank you for choosing NPs and AANP and your source for continuing education. (upbeat music) (upbeat music)