Latest / The Antisocial Doctors Podcast / Episode 25: Are Thermography & QT Ultrasounds Good Alternatives To Mammograms?

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Episode 25: Are Thermography & QT Ultrasounds Good Alternatives To Mammograms? · The Antisocial Doctors Podcast

1:27
Sonia Singh MD: You're listening to The Anti-Social Doctors podcast hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety.
1:38
Rebecca Berens MD: And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating.
1:43
Sonia Singh MD: We're also millennial women, anxious moms, and curious humans navigating social media.
1:48
Sonia Singh MD: We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
1:56
Rebecca Berens MD: This podcast is meant to be the antidote to your doomscrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health.
2:05
Rebecca Berens MD: In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion.
2:12
Sonia Singh MD: This is not your average debunking podcast.
2:15
Sonia Singh MD: We wanna explore not just what is trending on social media, but why.
2:18
Sonia Singh MD: Why are so many people drawn to this?
2:20
Sonia Singh MD: What is the nugget of truth here?
2:21
Sonia Singh MD: What are the facts?
2:23
Sonia Singh MD: What can we learn from this as patients and doctors?
2:25
Sonia Singh MD: No shame, no blame, no snark.
2:27
Rebecca Berens MD: We're so glad you're here
2:41
Sonia Singh MD: Rebecca Hi, Sonia All right, are you ready for part two of our two-part series on breast cancer screening methods?
2:51
Rebecca Berens MD: I am so ready.
2:53
Sonia Singh MD: This is probably the juicier por- portion of this series.
2:57
Sonia Singh MD: So I'll start with a, a slightly different patient story than I shared last time, and if anybody is listening to this episode and they haven't listened to our episode about whether mammograms are causing us harm or hurting us, I would strongly recommend listening to that first,'cause I think that's good context.
3:12
Sonia Singh MD: I'll review some of the main take-home messages of that a little bit later, but I think it's best to listen to both of these if you're gonna listen to one or the other.
3:20
Sonia Singh MD: So anyway, the patient story that came to mind about this was what prompted me to even do this episode, which was a few months ago, I had a patient reach out to me and I had actually suggested to her that it was time for her first mammogram, and I was asking her where she wanted me to send the order, and she said actually, can you order me a QT scan?" And I had never even heard of a QT scan before that, and so I was like,"Tell me more about that," and she sent me a link to a website, and I looked at the website, and obviously the website made it sound great.
3:52
Sonia Singh MD: And then I went to Open Evidence and PubMed and, did a little more research on it, and asked her,"You've never had a mammogram before.
3:59
Sonia Singh MD: Is there a reason you're going straight to this?" And she said the thing is I'm really worried about the radiation, and I'm really worried about the discomfort, and I heard that QT scans are better, and that they're painless, and that there's no radiation, so I don't really see why I wouldn't do this option." And that was the first time I did a little bit of reading on it, and now I've done a much deeper dive and know even more, and so I'm excited to share that, but I'm curious what you've heard about these scans before.
4:27
Rebecca Berens MD: Yeah, so I've definitely had a few patients who also are around the time that they need their first mammogram, usually people that have never had one before who have asked me mostly about thermography, not so much QT scans.
4:38
Rebecca Berens MD: They'll send me sometimes a TikTok video link or sometimes they'll just say,"Hey I've, I heard about this thermography.
4:46
Rebecca Berens MD: I heard it's better than mammogram or it's, safer than mammogram.
4:49
Rebecca Berens MD: What do you think?" I haven't heard as much about the QT scan, but I have seen lots of content about QT scans- on my personal social media where, which I was like,"What is this?" And yeah, so I'm very interested to hear what you found when you did your deep dive,'cause I looked at it and I was like,"Okay, I don't know about this," and that's kinda where I left it.
5:12
Rebecca Berens MD: I didn't do much research,
5:14
Sonia Singh MD: I have been sending you breadcrumbs of things that I have found over the last week- and- It's all quite alarming, honestly.
5:19
Sonia Singh MD: But we're gonna cover both thermography and QT scans, and I'm gonna also talk briefly about ultrasounds and MRIs, because I think a lot of people sometimes ask the question why wouldn't I just do one of those if they're better and don't have radiation, are more comfortable," et cetera.
5:32
Rebecca Berens MD: Yeah.
5:33
Sonia Singh MD: Basically the topic today is are QT ultrasounds and thermography, or ultrasounds or MRIs acceptable alternatives to mammography?
5:41
Sonia Singh MD: So what is the claim?
5:42
Sonia Singh MD: The claim is that mammograms are uncomfortable, they can be very painful, they can expose you to harmful radiation, and also within that claim, that they're this antiquated, old-school option.
5:53
Sonia Singh MD: It's like you put your breast in a vice, why would we be doing that?
5:55
Sonia Singh MD: Isn't there something better?
5:57
Sonia Singh MD: There's gotta be alternatives that are superior to that.
6:00
Sonia Singh MD: Like I said, some people will say why not just do ultrasound?
6:02
Sonia Singh MD: Why not go straight to MRI if that's the more advanced testing?
6:06
Sonia Singh MD: If you have the money and you have a doctor willing to order it, why would you not just do the more detailed and advanced test and skip the option that has discomfort and radiation?" One thing I learned through researching this is I think a lot of the people who do support the alternatives to mammography will often then go straight to MRI if they see anything on their alternative test that- Okay makes them concerned.
6:28
Sonia Singh MD: So QT Imaging or QT Ultrasound or QT scans and thermography are proposed alternatives to mammogram.
6:35
Sonia Singh MD: The QT Imaging is like the big company that does a lot of these and their website says that it provides, quote,"Safer, earlier, and more accurate care." Honestly, I do not know how they can legally say that- but that is on the website.
6:47
Sonia Singh MD: There's a, another company that's physician-run that's called Perfection, and on Perfection Imaging website, they say,"The QT scan uses gentle sound waves, not radiation, while your breast rests in warm water.
6:59
Sonia Singh MD: In minutes, a true 3D picture with clarity even through dense tissue.
7:03
Sonia Singh MD: Then, a real conversation so results become a plan instead of worry." And one of their big messages is,"Find the right imaging for you." So I think that the claim there is like,"Mammograms might be fine for the plebeian masses, but you- your breasts should be resting in a warm bath of water." And then, you know- I couldn't, for thermography, I couldn't find like for QT, I feel like there's a few big companies.
7:31
Sonia Singh MD: For thermography, it feels like it's like- Not like one big national company that does it.
7:37
Sonia Singh MD: It's a lot of independent small practitio- pr- practices and clinics.
7:40
Sonia Singh MD: So I looked at a local practice that does thermography for a lot of this content, but they describe thermography as, quote,"A brilliantly simple and completely harmless clinical imaging technology that takes a picture of the body's thermal infrared patterns.
7:54
Sonia Singh MD: It's unique in that it sees the function or physiology occurring real time.
7:59
Sonia Singh MD: Other imaging technologies, such as MRI or X-ray, detect anatomic changes and abnormalities, but miss conditions like active inflammation, referred pain, infection, or angiogenesis." I also listened to a couple of biohacking podcasts, and on one, the person claimed that they basically can, quote,"Detect breast cancers before they even exist," because they are able to detect- Don't laugh, Rebecca, okay?
8:24
Sonia Singh MD: We can't be snarky.
8:25
Sonia Singh MD: Detect- I'm not
8:26
Rebecca Berens MD: being snarky, I'm just like, how can you tech- detect something that doesn't exist?
8:30
Rebecca Berens MD: That seems
8:31
Sonia Singh MD: like a contradiction.
8:31
Sonia Singh MD: They detect areas of active inflammation that are at risk for becoming a breast cancer.
8:37
Sonia Singh MD: That's how they do that, okay?
8:38
Sonia Singh MD: I
8:38
Rebecca Berens MD: mean- And you know- there's lots of things that are inflamed that do not turn into breast cancer.
8:42
Rebecca Berens MD: But anyway, we'll...
8:44
Rebecca Berens MD: I'll move on.
8:45
Sonia Singh MD: Yeah, and you know what?
8:46
Sonia Singh MD: Sometimes inflammation is an appropriate response to something.
8:49
Sonia Singh MD: Yeah.
8:49
Sonia Singh MD: No one ever talks about that, but anyway, forgetting that.
8:52
Sonia Singh MD: That's a- that's for an episode on inflammation.
8:53
Sonia Singh MD: Yeah.
8:54
Sonia Singh MD: It's funny'cause one of the themes that I've seen a lot in, like, when I listen to these podcasts is they'll- they'll make a certain claim on their website, which is usually kinda sanitized and mild and worded very carefully, yeah.
9:06
Sonia Singh MD: But then what th- these people will say on a podcast is often just way more extreme and it's a game of telephone.
9:13
Sonia Singh MD: They've exaggerated it, which I- I can only imagine what gets said in an exam room where there's nobody to keep them accountable or to fact check them or say,"Hey, is that really true?" So anyway, just an observation.
9:24
Sonia Singh MD: But those are the claims around these two technologies and I won't go deeply into, all the suspicion around mammograms,'cause that was in our previous episode, but yeah, I'm curious if there's anything else you wanted to add to that.
9:36
Rebecca Berens MD: Yeah, no, I think that's, That's a lot of what I've seen as well.
9:39
Rebecca Berens MD: The first time I ever heard about thermography I think was from a patient, when I Googled it, found very similar type of wording on websites that popped up with it.
9:48
Rebecca Berens MD: And yeah I can definitely see how the careful wording for legal purposes- would be different in a conversation.
9:55
Rebecca Berens MD: God bless you for listening to those podcasts.
9:57
Rebecca Berens MD: I cannot.
9:59
Sonia Singh MD: It's just really important context,'cause I just think, I try to listen to those episodes thinking about if I was just coming into this with no context or background, what would I think?
10:09
Sonia Singh MD: And with all of them, I would be terrified.
10:12
Sonia Singh MD: I would be terrified of mammography, and I would be like,"Oh, this obviously is a better solution," because they just leave out so many important details and-
10:20
Rebecca Berens MD: Yeah
10:21
Sonia Singh MD: also kind of- again, like the way she described like I can catch it before it even becomes a cancer." That's a huge claim, to make, and-
10:29
Rebecca Berens MD: Very appealing.
10:30
Rebecca Berens MD: Very appealing
10:30
Sonia Singh MD: Very appealing, of course.
10:32
Sonia Singh MD: Okay, so let's talk more about why it's viral.
10:35
Sonia Singh MD: So I'm not gonna...
10:36
Sonia Singh MD: we talked a lot about this in the previous episode, and a lot of the same things apply.
10:39
Sonia Singh MD: I'm not gonna go deeply into them.
10:41
Sonia Singh MD: A few of them, just to summarize, were that breast cancer is scary.
10:44
Sonia Singh MD: It's very common.
10:45
Sonia Singh MD: It's the most common cancer in US women.
10:47
Sonia Singh MD: Most people have some experience with it or with somebody who's had it.
10:50
Sonia Singh MD: Mammograms can be uncomfortable and they're anxiety-provoking for people.
10:54
Sonia Singh MD: It's not a fun thing to do.
10:55
Sonia Singh MD: And so it's, not surprising that people would be attracted to an, a painless alternative.
11:00
Sonia Singh MD: I think there is increasing concern about radiation exposure.
11:03
Sonia Singh MD: We have so many more devices.
11:04
Sonia Singh MD: I think people worry about what is the cumulative risk even if all of these things are, individually not so bad?
11:10
Sonia Singh MD: General distrust of the medical establishment, which we've talked about a lot.
11:13
Sonia Singh MD: The idea that doctors are, benefiting financially from ordering these tests, and so they just wanna keep doing it.
11:19
Sonia Singh MD: The idea, the, a claim that is said a lot by a certain physician who supports these alternatives is I don't remember exactly how she phrased it, but she basically says that mammograms create more breast cancer patients, and so that's a big part of the motivation why people do that.
11:31
Sonia Singh MD: Yeah.
11:31
Sonia Singh MD: Also again, this idea that whatever's covered by your insurance is kinda like the low-tech, cheap, crappy option, and all these other advanced options are available outside of insurance for those who can pay.
11:42
Sonia Singh MD: Growing recognition that women's health has been understudied and neglected, so I think there's this general sense of"Oh, are we just doing this'cause no one cares about us, and they haven't offered us, more advanced technology?" Confusion around what to do with dense breasts.
11:56
Sonia Singh MD: I talked about this a lot in our last episode.
11:57
Sonia Singh MD: And then I think this is a big one for this particular episode, fear around mammograms, which is ironic because it is the same people who create the fear around mammograms who now have the solution for us.
12:12
Sonia Singh MD: When I mentioned in the last episode, when I just looked up mammogram in Spotify podcasts to see what are the top-rated, most relevant episodes about where people talk about mammograms, the same doctor appeared in so many of them.
12:26
Sonia Singh MD: And now I have counted, and they were all negative, towards mammograms.
12:29
Sonia Singh MD: I've now counted that she's been on over 20 different podcasts, the same doctor- basically stoking fear around mammogram, talking about the radiation exposure, talking about that, it's to create more cancer patients and to support this, cancer industrial complex.
12:47
Sonia Singh MD: And mostly these podcasts are, functional medicine podcasts, Crunchy Mom podcasts, biohacking podcasts.
12:52
Sonia Singh MD: She's really targeting that demographic, and she is very loud, and I think in that community probably very well known for her perspective.
13:01
Sonia Singh MD: And she is a physician.
13:02
Sonia Singh MD: She is a board-certified surgeon.
13:05
Sonia Singh MD: And she also talks a lot about herself being a cancer survivor, although she had thyroid cancer, and she had a lot of breast cancer in her family.
13:12
Sonia Singh MD: But she's a brilliant speaker, a brilliant storyteller.
13:17
Sonia Singh MD: Her narrative is very compelling.
13:19
Sonia Singh MD: And all the titles of the podcasts that she i- episodes that she is on are always"The dirty truth about mammograms,""What your doctor is not telling you about breast cancer,""What doctors miss about breast cancer,""The myths around mammograms." Th- very clickbaity, attractive titles.
13:35
Sonia Singh MD: And, what does she do now?
13:37
Sonia Singh MD: She runs a company that does QT scans.
13:39
Sonia Singh MD: Again, a common theme in the wellness world is to stoke and create a lot of fear around something, and then to offer you the solution, when prior to them talking about it, you didn't have the fear to begin with.
13:53
Rebecca Berens MD: Yeah.
13:53
Sonia Singh MD: So-
13:54
Rebecca Berens MD: Create, creating patients for yourself.
13:56
Sonia Singh MD: Create...
13:56
Sonia Singh MD: What do you know?
13:57
Sonia Singh MD: How- That sounds familiar.
14:00
Sonia Singh MD: Creating a customer, yes.
14:02
Sonia Singh MD: And she has a lot of"This is the new standard of women's health.
14:06
Sonia Singh MD: If you've ever put off screening because of pain or radiation or fear, this was built for you." Really effective and beautiful marketing.
14:13
Sonia Singh MD: So anyway, whoever is doing her marketing you're on point.
14:16
Sonia Singh MD: You're doing a good job.
14:17
Sonia Singh MD: It's working.
14:18
Sonia Singh MD: Do you have anything to add on this particular
14:21
Rebecca Berens MD: topic?
14:21
Rebecca Berens MD: No, I think the thing about, you know- women's health being understudied and that no one cares and that's why no one's bothered to try to find another option for us that doesn't suck.
14:34
Rebecca Berens MD: I think the- I see that sort of vibe a lot.
14:38
Rebecca Berens MD: And I think there's a lot, like you said, a lot of distrust.
14:40
Rebecca Berens MD: There's a lot of division socially, politically.
14:44
Rebecca Berens MD: And I think that is added in to the whole gender wars and political wars and things like that of this is a political statement, not just a, concern about the imaging.
14:58
Rebecca Berens MD: It's like, I'm a little bit concerned, but also this is an identity that I have affiliated with my political- Yeah belief and my gender and all of these things.
15:06
Rebecca Berens MD: So it's so much stronger than just responding to marketing.
15:09
Rebecca Berens MD: It becomes an identity.
15:11
Sonia Singh MD: Yeah, that's a great point.
15:12
Sonia Singh MD: I think it can almost be framed like a feminist choice to say- Yeah"No, I refuse to do what this, paternalistic, patriarchal medical establishment has chosen for me, and I'm gonna do-" Yeah or an act of self-advocacy or self-agency.
15:27
Sonia Singh MD: It's like no." Yeah.
15:27
Sonia Singh MD: "I am choosing this option," not just the standard thing that everyone- Yeah blanket recommendation for everyone else.
15:33
Rebecca Berens MD: Yeah.
15:33
Sonia Singh MD: Yeah, and I, I think with her company specifically, it's very much framed as a elevated self-care kind of choice, yeah.
15:41
Sonia Singh MD: It's like,"I shall choose to have this much nicer experience instead of the cold metal," you know- Yeah"device that most people are gonna get." Okay, so let's talk about what the nugget of truth is behind some of these claims.
15:54
Sonia Singh MD: So mammograms are uncomfortable.
15:56
Sonia Singh MD: Mammograms do expose you to some radiation.
15:59
Sonia Singh MD: If you're curious about that or wanna understand more about that, the last episode was, mostly talking about radiation and how much radiation and what are the harms of that and what are the consequences are.
16:08
Sonia Singh MD: But yes, it does expose you to radiation.
16:11
Sonia Singh MD: Mammograms are less sensitive in women with dense breasts, and there is still pretty active debate about what we should do with that and what is the ideal screening for those women.
16:21
Sonia Singh MD: Mammograms can lead to false positives, and they can also lead to other harms, the stress and anxiety of being called back, a biopsy that ends up being benign, additional imaging that ends up being benign.
16:31
Sonia Singh MD: There are downsides to mammograms.
16:33
Sonia Singh MD: The other truth here is that although mammograms have been shown to reduce breast cancer mortality, they have not been shown to reduce all-cause mortality.
16:42
Sonia Singh MD: We discussed this again in depth in the last episode, but the very boring statistical explanation for that is that the studies on mammography are just not powered to detect reductions in all-cause mortality.
16:55
Sonia Singh MD: They would be less than 1% because a lot of women don't end up dying of their breast cancer, and we're really good at treating it now.
17:01
Sonia Singh MD: And so you'd have to have a study with over a million participants to really start to detect that change, and there's no other screening except, I think I talked about it in the last episode, one specific lung cancer screening that, that has ever met that standard of reducing all-cause mortality.
17:18
Sonia Singh MD: So a lot of times you'll hear these people say,"It doesn't save lives.
17:22
Sonia Singh MD: It hasn't been shown..." It's been shown definitively to reduce breast cancer mortality, but not all-cause mortality, but that is really because of a statistical situation and the design of the studies rather than because it's a bad screening tool.
17:38
Sonia Singh MD: And it is also true that these proposed alternatives that we're gonna talk about, a- all of them do not expose you to ionizing radiation, and that most of them are going to be more comfortable than a mammogram for a lot of women.
17:52
Sonia Singh MD: And in case you did not listen to the last episode and you're doubting whether we are supportive of mammograms or not, the bottom line of the last episode, I would say, was that, we did a overview of all of the potential harms of mammography, the, including the risk of radiation and how many, cancers might that actually cause and blah, blah, blah.
18:12
Sonia Singh MD: And I think the conclusion for us was that for women aged 50 to 70, it seems pretty clear that benefits outweigh harms.
18:22
Sonia Singh MD: For women 40 to 50, it's a little bit more of a complicated picture, although most societies will still support mammography for screening, and there is still debate over what frequency is ideal.
18:32
Sonia Singh MD: And then we really emphasize that the risk-benefit equation can vary depending on who you are and all your individual factors, like your family history, your breast density, how anxious you are, so many different things
18:44
Rebecca Berens MD: that- But that's the other harm, right?
18:45
Rebecca Berens MD: It's not just radiation, it's also the callbacks, the- Yes, yeah biopsies, that, the anxiety and quality of life impact that has.
18:54
Rebecca Berens MD: So these are also real harms to consider.
18:57
Sonia Singh MD: Yes.
18:57
Sonia Singh MD: So we talked through all of that in the last episode.
18:59
Sonia Singh MD: Okay now let's talk about what are the facts around these alternatives with context and nuance.
19:07
Sonia Singh MD: First I'm gonna briefly talk about ultrasounds and MRIs, just c-'cause I think a lot of people are just like why don't we just do those?"'Cause a lot of people have had the experience of having the mammogram and then being sent for either an ultrasound or an MRI.
19:18
Sonia Singh MD: So the thought is if this has radiation and those don't, and they're more detailed, why would I not just go to that?" I found one head-to-head trial of ultrasound alone versus mammography in the same group of women with dense breasts.
19:31
Sonia Singh MD: So take note, this is not an average population.
19:33
Sonia Singh MD: This is a population with higher risk, and in which we know mammography doesn't perform as well.
19:39
Sonia Singh MD: It actually found no difference in detection rates of cancer, but they found much higher rates of false positives with the ultrasound.
19:47
Sonia Singh MD: So more callbacks for biopsies that turned out to be benign.
19:51
Sonia Singh MD: And the other issue with ultrasound is that it's operator-dependent, so it requires a skilled technician to actually perform the ultrasound, and it takes more time than mammography would take.
20:01
Sonia Singh MD: So that was the only one comparing it head-to-head with mammography.
20:05
Sonia Singh MD: Now the other question is of adding ultrasound to mammography, which I know some women with j- dense breasts will choose to do.
20:12
Sonia Singh MD: So when you add ultrasound to mammography for women with dense breasts, you get an incremental cancer detection rate of 1.8 to 4.6 per 1,000.
20:22
Sonia Singh MD: So basically between two and five additional breast cancers are gonna be detected in 1,000 women if you add ultrasound to mammography.
20:31
Sonia Singh MD: But in women with non-dense breasts, there's almost no improvement in the detection rate, and it will significantly increase false positives by almost w- 1.5 to 2.
20:41
Sonia Singh MD: So you're almost doubling your rate of false positives to get a small improvement for women with dense breasts and to get no improvement for women without dense breasts.
20:50
Sonia Singh MD: So e-
20:51
Rebecca Berens MD: just- Quick question.
20:52
Rebecca Berens MD: Were those false positives just for Dense breasts or just for non-des- dense breasts-
20:58
Sonia Singh MD: For all
20:58
Rebecca Berens MD: just for information?
20:59
Rebecca Berens MD: Okay.
21:00
Sonia Singh MD: Yeah.
21:00
Sonia Singh MD: So basically, it just dramatically increases the callbacks and the biopsies, and then only in women with dense breasts does it seem to improve the detection rate.
21:09
Rebecca Berens MD: Got it.
21:09
Sonia Singh MD: So that being said, there are clear indications for ultrasound where it is appropriate.
21:15
Sonia Singh MD: So for women under 30 who are symptomatic, have a breast symptom, so like a lump, a mass, localized pain ultrasound is an appropriate tool for those women.
21:25
Sonia Singh MD: The idea there is that younger women have denser breasts, so mammography is not gonna be as good in them.
21:30
Sonia Singh MD: They're also lower risk for an actual cancer, so just the pre-test probability of actual malignancy is lower.
21:36
Sonia Singh MD: You probably are gonna be doing a targeted eval as opposed to just ultrasounding, both breasts without having any idea what you're looking for.
21:43
Sonia Singh MD: And you wanna avoid radiation in those women that could be nursing, pregnant, trying to get pregnant, younger, and just having a whole lifetime of potential radiation exposure ahead of them.
21:53
Sonia Singh MD: So for them it's appropriate.
21:54
Sonia Singh MD: For women who are pregnant or lactating, it's appropriate.
21:56
Sonia Singh MD: For women who have a screening mammogram who are over 30 or symptoms with a mammogram that's abnormal, so it can be the second step after you do a mammogram in older women.
22:07
Sonia Singh MD: And then lastly, in high-risk women who can't undergo an MRI in that case, ultrasound can also be considered as an additional screening tool.
22:15
Sonia Singh MD: And again, in that case, you have a higher pre-test probability, so you're assuming that more of the things that you're detecting are going to be real compared to somebody who's low risk.
22:24
Sonia Singh MD: Okay, so that's the story with ultrasound.
22:26
Sonia Singh MD: Any questions on ultrasound before I move to MRI?
22:30
Rebecca Berens MD: No, I think that makes sense, although I do wanna say pregnancy, yes, I think the ultrasound's definitely preferred initially because radiation with a fetus is a whole different situation.
22:38
Rebecca Berens MD: But I was under the impression that for lactation it was still mammogram.
22:43
Sonia Singh MD: Yes, that's a good point.
22:44
Sonia Singh MD: I think maybe the recommendation might vary depending on why you're doing it.
22:48
Sonia Singh MD: I had a woman who had a genetic mutation and was very high risk, and I remember for her, when she was lactating, it was still appropriate to get the mammogram, and I had to fight with the- Yeah mammography place- Yeah, but sometimes you're,
22:58
Rebecca Berens MD: like, fighting with
22:59
Sonia Singh MD: them, and it might-'Cause they didn't wanna do it.
23:01
Sonia Singh MD: And they kept telling me,"No, order an ultrasound." And I was like,"No, I'm looking at the guideline.
23:04
Sonia Singh MD: It says mammography." So I think it may depend on the exact circumstances.
23:09
Rebecca Berens MD: Sure.
23:09
Rebecca Berens MD: And certainly if it's a diagnostic indication and not just a screening, that's very different.
23:15
Rebecca Berens MD: The imaging choice- Algorithm.
23:17
Rebecca Berens MD: In a diagnostic situation is very different.
23:19
Rebecca Berens MD: Diagnostic being there's a symptom or concern, versus screening- No symptoms, we're just purely looking in case there's a breast cancer, right?
23:27
Rebecca Berens MD: So I think that's a, that's an important distinction that I think is also a little bit hard for maybe someone non-medical to differentiate.
23:35
Rebecca Berens MD: 'Cause it is confusing when you're like if they're just gonna send me for an ultrasound, why wouldn't I just start with that?"
23:40
Sonia Singh MD: Why not just do a
23:40
Rebecca Berens MD: screen for that?
23:40
Rebecca Berens MD: Yeah.
23:41
Rebecca Berens MD: But it's different, the ultrasound has a much different, role when you're- Yeah evaluating an abnormality versus doing a screening.
23:49
Rebecca Berens MD: So anyway, just think that's I think a hard thing to talk about with a patient sometimes'cause- Yeah, I- it seems very counterintuitive.
23:57
Sonia Singh MD: Yes, and I think what a lot of this whole conversation comes back to is like- The oversimplification when someone's like which test is better?" And it's like, better for what?
24:07
Sonia Singh MD: In whom?
24:08
Sonia Singh MD: And for- Yeah with what goal?
24:10
Sonia Singh MD: And it's the same question we try to ask about interventions and tests and supplements.
24:14
Sonia Singh MD: It's it's not just is it good or bad, or is is a MRI better than ultrasound?
24:17
Sonia Singh MD: Is ultrasound better than mammography?
24:19
Sonia Singh MD: It's it- s- they all have their strengths and weaknesses, and, there's certain times when you really want a high sensitivity.
24:25
Sonia Singh MD: There's certain times when you really need a high specificity, and usually there's some sort of trade-off where you're- Yeah losing one and gaining the other.
24:30
Sonia Singh MD: So they all have a role together, and luckily it's not up to you or I to try to figure that out.
24:36
Sonia Singh MD: There are smart, really smart people that look at all this data and try to help us figure out what makes the most sense to do.
24:42
Sonia Singh MD: But anyway, let's talk about MRI.
24:44
Sonia Singh MD: So breast MRI is substantially more sensitive than mammography.
24:48
Sonia Singh MD: It will detect more cancers at earlier stages, but at the cost of lower specificity, more false positives more recalls, and more biopsies.
24:58
Sonia Singh MD: So just to give you a sense of the scale, the recall rate for MRI is around 15%, and for mammography is like 6.4%.
25:06
Sonia Singh MD: The biopsy rate for MRI is 12%, for mammography is 2.4%.
25:10
Sonia Singh MD: And there's no randomized control trials looking at MRI with breast cancer mortality, so there's also just no study that tells us exactly what that reduction is.
25:19
Sonia Singh MD: MRI sensitivity ranges from 71 to 100%, versus mammography which can be like 77 to 95%.
25:27
Sonia Singh MD: Now, that number, when I was trying to look at just sensitivity for mammography, I found a broad range of numbers.
25:34
Sonia Singh MD: What I can tell you is that there's clearly a really big drop-off when you increase breast density.
25:41
Sonia Singh MD: So the more- dense the breasts get, like sometimes these numbers are going 40-ish perc- they're getting much, much lower.
25:46
Sonia Singh MD: And then I'm sure age plays a role in that, because age also influences density.
25:50
Sonia Singh MD: So just when I say these numbers, if you find a different number, I believe you.
25:55
Sonia Singh MD: It's just- I had to pick o- I had to pick one, so 77 to 95 is the commonly reported range that I've been seeing for mammography.
26:04
Sonia Singh MD: And then MRI has a specificity of 81 to 98%, whereas mammography has a specifi- specificity of 93 to 100%.
26:12
Sonia Singh MD: So specificity is better for mammography compared to MRI.
26:16
Rebecca Berens MD: And just for any non-stats medical person, specificity means when it's positive it's actually truly positive.
26:25
Rebecca Berens MD: Versus, it's positive but it's a false positive or- For
26:28
Sonia Singh MD: some other reason.
26:28
Rebecca Berens MD: Yeah.
26:29
Sonia Singh MD: Yeah.
26:29
Rebecca Berens MD: Yeah.
26:30
Sonia Singh MD: And sensitivity refers to, how many of the true cases did you actually identify correctly?
26:35
Rebecca Berens MD: Yeah.
26:35
Sonia Singh MD: Yeah.
26:35
Sonia Singh MD: The other thing you have to consider with MRI compared to mammography is that you have to give gadolinium contrast, and so then you have the risk of allergic reactions various other reactions to the contrast.
26:46
Sonia Singh MD: Claustrophobia, it that sounds just kinda like a footnote"Oh yeah, some people are claustrophobic," but in one of the studies I saw 40% of the women declined to do the MRI portion of the study because of claustrophobia.
26:56
Sonia Singh MD: So it's not insignificant, how many people truly feel very uncomfortable in an MRI scanner.
27:02
Sonia Singh MD: And
27:02
Rebecca Berens MD: then also have to take a- A med to tolerate
27:05
Sonia Singh MD: it?
27:05
Rebecca Berens MD: Yeah also to be able to tolerate it.
27:06
Rebecca Berens MD: Then you're taking medication, which granted is not long-term medication, but you're taking a medication, which also has a potential side effect profile, Yeah just to get the scan done.
27:16
Sonia Singh MD: And then lastly, there is the higher cost.
27:19
Sonia Singh MD: So I do want to point out, though, that I think in a lot of people's minds, the cost feels like the main barrier, like the reason that everyone's not just getting an MRI.
27:29
Sonia Singh MD: You and I have probably both been in the position of fighting with someone's insurance to get a breast MRI approved for them- because it is a more expensive-
27:37
Rebecca Berens MD: Yeah
27:37
Sonia Singh MD: test.
27:38
Sonia Singh MD: But I just wanna point out that from everything I said there's many other reasons that MRI is not the standard screening tool, and is really not just a cost-based decision.
27:47
Rebecca Berens MD: Yeah, and I think people really do when cost is even brought up, they're like,"Oh, you're just gatekeeping because you wanna, Right The people don't wanna pay for things.
27:56
Rebecca Berens MD: My insurance is trying to make money," which, is true.
27:58
Rebecca Berens MD: But but also it, that doesn't, that's not the only consideration.
28:02
Rebecca Berens MD: But we do have to factor it in because for someone to get a screening done, potentially on an annual basis, that becomes a real, impact on their entire life if they're having to pay an out-of-pocket cost.
28:14
Rebecca Berens MD: 'Cause also,
28:14
Sonia Singh MD: Yeah
28:15
Rebecca Berens MD: the, especially when it's done, in a more diagnostic way, it's not 100% covered you know- Yeah a screening mammogram is.
28:21
Rebecca Berens MD: So it's, I think it's just it's an important concept to bring up.
28:24
Rebecca Berens MD: I also will say regarding cost though, I think there's a lot of people that would hear everything you just said and say"Okay, it's more sensitive.
28:32
Rebecca Berens MD: Even if I have to get a false positive or a biopsy, I would rather that than-" miss something, and I'm willing to pay to do that." Okay.
28:41
Rebecca Berens MD: So I'm curious your thoughts on that,'cause I have a subset of patients who are like,"I wanna do every single possible thing that I could possibly do, and I don't care the cost."
28:54
Sonia Singh MD: So if that person had a condition that made them high risk, like extremely dense breasts or a family history or lifetime risk greater than 20% or genetic, then I'm good with the MRI, okay?
29:05
Sonia Singh MD: If they were of average risk and they had no indication to do the additional screening, I would say The data suggests that doing that is going to put you through more medical procedures and potentially from that, more harm.
29:24
Sonia Singh MD: And I think it's just hard to appreciate that until you've done it.
29:28
Sonia Singh MD: Yeah.
29:29
Sonia Singh MD: And I g- I, again, I don't know that I would be 100% opposed to it, but to me that would, like that would be a very fear-driven, anxiety-driven decision, and I would probably try to explore that a little bit more.
29:42
Sonia Singh MD: Yeah.
29:42
Rebecca Berens MD: Yeah.
29:42
Rebecca Berens MD: I think it, there, there's a whole, I think, change recently where, people have access to so much more medical information than they ever did before.
29:51
Rebecca Berens MD: And I think people feel more like,"I should get to decide.
29:55
Rebecca Berens MD: Why should the doctor get to decide what I do and don't get?" If I make the decision, patient autonomy, which, fair.
30:01
Rebecca Berens MD: But I think it's also as the doctor, you're like,"I don't want you to go through this unnecessarily.
30:07
Rebecca Berens MD: I don't want to order it and then you have this outcome, and I knew it wasn't really necessary, and then I feel like I contributed to this harm."
30:15
Sonia Singh MD: Yeah.
30:15
Sonia Singh MD: That's
30:15
Rebecca Berens MD: a whole different thing.
30:16
Rebecca Berens MD: The whole Hippocratic Oath, like the first do no harm.
30:18
Rebecca Berens MD: And so this is the interesting thing where there's so much more elective medical stuff now that kind of bypass the doctor.
30:24
Rebecca Berens MD: And I, it, I don't know.
30:25
Rebecca Berens MD: It's just an interesting concept of Previous paternalism in medicine that's been, longstanding, and this sort of shift to bypassing the doctor because of that.
30:35
Rebecca Berens MD: I don't know.
30:36
Rebecca Berens MD: I think it's just an interesting conversation.
30:37
Rebecca Berens MD: Okay.
30:37
Rebecca Berens MD: I have a counter- We have to go deep into that another time.
30:39
Sonia Singh MD: No, I have a counter-hypothetical for you.
30:41
Sonia Singh MD: This is like a PCP Would You Rather.
30:43
Sonia Singh MD: Okay.
30:44
Sonia Singh MD: So we kinda talked about this in the full body MRI episode, okay?
30:48
Sonia Singh MD: Yeah.
30:49
Sonia Singh MD: So let's say you had a patient who was just really anxious about breast cancer, and she did not meet any of the criteria for, additional screening, and there was no other features that made her high risk, but she was just like,"I'm just re- my best friend had it.
31:00
Sonia Singh MD: I'm just so nervous about breast cancer." Would you rather her get- A full body MRI at one of these standalone no doctor required places?
31:11
Sonia Singh MD: Or would you rather order her a dedicated breast MRI?
31:15
Sonia Singh MD: Because as we talked about in that episode, the full body MRI is nowhere near equivalent to a dedicated breast MRI.
31:23
Sonia Singh MD: Oh, yeah.
31:24
Sonia Singh MD: So it is not like,"Oh, I got my Prenuvo now I'm good for my breast cancer imaging." So what would you tell that person?
31:30
Sonia Singh MD: I'm curious.
31:31
Rebecca Berens MD: So would I rather?
31:32
Rebecca Berens MD: I would rather order it.
31:34
Sonia Singh MD: Yeah.
31:34
Rebecca Berens MD: Because then we know that it was, the quality was good.
31:39
Rebecca Berens MD: But with the caveat that I'm explaining in full detail there is this risk of all of these this cascade of interventions that will happen potentially after this that may be completely unnecessary, not to mention the additional cost, not to mention pot- potential complications of those interventions.
31:56
Rebecca Berens MD: A- and I think it just, it does become an individual decision, and I feel like I've increasingly ended up in that situation where I'm ordering things that I'm like- Yeah I don't wanna order this.
32:08
Sonia Singh MD: Yeah.
32:08
Sonia Singh MD: Same.
32:08
Rebecca Berens MD: Same.
32:09
Rebecca Berens MD: But I, we've had a, an informed consent discussion, and the patient really wants it.
32:12
Rebecca Berens MD: But it's just so interesting'cause I think the way we're trained is You give them the options and they pick one, not they come with their choice and you decide whether you will agree to it or not.
32:22
Rebecca Berens MD: It's just-
32:22
Sonia Singh MD: It's like a harm, it's like a harm reduction-
32:24
Rebecca Berens MD: Yes
32:25
Sonia Singh MD: kind of situation.
32:25
Sonia Singh MD: It, a- and actually, I end up in the same situation with GLP-1 sometimes, where-
32:29
Rebecca Berens MD: Yes.
32:30
Sonia Singh MD: Yeah I don't feel like there's a strong medical indication.
32:32
Sonia Singh MD: It's"Hey, maybe," and then I'm, not excited about it and I don't really think it's the right thing to do, but then I know that they're gonna go to some shady clinic down the street and get a compounded product and they're not gonna be monitored, and no one's gonna talk to them about diet- Yeah no one's gonna talk to them about the side effects, and they're gonna ramp up the do- and so then I'm like okay, I'd rather just order it through the manufacturer and I will manage.
32:52
Sonia Singh MD: I will do the prescription, and like I will watch." Yeah.
32:54
Sonia Singh MD: But that doesn't feel great either.
32:56
Sonia Singh MD: But anyway.
32:57
Sonia Singh MD: Yeah.
32:57
Sonia Singh MD: Yes, that is the era of medicine that we are in.
32:59
Rebecca Berens MD: Yeah.
32:59
Rebecca Berens MD: That could be a whole episode.
33:01
Rebecca Berens MD: So maybe we could do that, but yeah.
33:03
Rebecca Berens MD: It's
33:03
Sonia Singh MD: patient-directed medical management.
33:04
Rebecca Berens MD: It's patient-directed interventions, yeah.
33:06
Sonia Singh MD: Okay, anyway, so to round out what happens with MRI, so adding MRI to screening averts maybe one additional breast cancer death per 1,000, but it doubles the false positive rate in terms of follow-ups and biopsies recommended.
33:19
Sonia Singh MD: And so that is why, in general, it is reserved for the women who are at higher risk.
33:25
Rebecca Berens MD: Yeah.
33:25
Sonia Singh MD: Okay, so let's move on to thermography.
33:29
Sonia Singh MD: breast thermography, also known as digital infrared thermal imaging, works by detecting infrared radiation emitted from the skin surface and converting it into a color-coded temperature map, a thermogram.
33:43
Sonia Singh MD: And the premise of this is that if you can detect this increased temperature, you're detecting metabolic and vascular changes that might be overlying a tumor, and therefore it could alert you to areas of inflammation or malignancy.
33:57
Sonia Singh MD: How is it performed?
33:58
Sonia Singh MD: Typically, the patient will disrobe.
34:00
Sonia Singh MD: They will stand in a temperature-controlled room for 10 to 20 minutes to allow their body to settle in a temperature, and then they will have three to five images taken.
34:10
Sonia Singh MD: The entire process takes 30 minutes.
34:12
Sonia Singh MD: It's no contact and it's painless.
34:14
Sonia Singh MD: It's funny because I feel like both of these technologies people are like,"Oh, there's all kind of new things now," and actually neither of these is that new.
34:23
Sonia Singh MD: So this was first used for breast cancer detection in the 1950s.
34:27
Sonia Singh MD: And it was approved as an adjunct evaluation method, so not a primary diagnosis or screening method.
34:35
Sonia Singh MD: It was approved as an adjunct evaluation method in 1982.
34:39
Sonia Singh MD: It is not approved on its own to screen for, diagnose, or detect breast cancers.
34:44
Sonia Singh MD: And actually, since 1982, the FDA has issued multiple warning letters to clinics and providers that market it as if it is a mammogram alternative or a standalone test.
34:55
Sonia Singh MD: So why did it fall out of favor after the 1950s?
34:58
Sonia Singh MD: There were a variety of reasons.
35:00
Sonia Singh MD: So one reason was lack of standardization.
35:03
Sonia Singh MD: So there wasn't really a standard acquisition protocol for the images.
35:07
Sonia Singh MD: There wasn't a standard interpretation method.
35:09
Sonia Singh MD: The reliability of the test depends a lot on environmental factors like the ambient temperature, the humidity.
35:15
Sonia Singh MD: It can also vary based on patient-specific factors like hormonal factors, where they are in their menstrual cycle.
35:21
Sonia Singh MD: It can vary based on operator technique.
35:24
Sonia Singh MD: So there's just a lot of logistical standardization problems with the actual procedure.
35:30
Sonia Singh MD: That was number one.
35:30
Sonia Singh MD: Number two was overall poor research quality.
35:34
Sonia Singh MD: So when they do review articles or reviews of these studies like one review basically said there was 100% heterogeneity, genity in the studies where they were never using the same imaging protocol, the patient selection factors were totally different, the sample sizes were variable, the camera type that they were using was variable.
35:52
Sonia Singh MD: And when you look at a lot of these studies, they're in digital engineering.
35:58
Sonia Singh MD: Like they're in these journals that are really talking about the technology of the machine itself and image processing- And there's very few studies on clinical outcomes with this technology.
36:08
Sonia Singh MD: The other thing was its performance.
36:11
Sonia Singh MD: So its pooled sensitivity was around 88%.
36:14
Sonia Singh MD: So we learned that for mammography it's more like high 80s to 90s, so sensitivity's worse than a mammography.
36:20
Sonia Singh MD: And the specificity was only around 72%, so like far, pretty significantly inferior.
36:26
Sonia Singh MD: So 3D mammo, like one estimate I found on the, lower side was like maybe 88% sensitivity, and then 92% specificity, and these were, in the lower range of the estimate, so compared to 88 and 72.
36:38
Sonia Singh MD: So mammogram clearly seems better.
36:41
Sonia Singh MD: The downside of mammogram though, as we've discussed, is that it's going to vary based on breast density, and thermography does not vary based on breast density, so that is one of its strengths.
36:51
Sonia Singh MD: Now, the big caveat to this, there's a few papers out there that are just like thermography has been unfairly thrown out, it's been prematurely thrown out, and we need to reexamine it.
37:01
Sonia Singh MD: And the arguments that those people make are basically that the newer cameras that are available now are far superior to the cameras that existed at the times that all that original research was going on and that AI machine learning has basically made the technology a lot better and has made it so that no human needs to actually read the result.
37:21
Sonia Singh MD: It can be read by a machine.
37:23
Sonia Singh MD: They also continue to argue that it's painless and contactless and quick, and so maybe there would be better uptake of it than of the traditional screening mammography.
37:31
Sonia Singh MD: And I thought this was a reasonable argument, that performing the test and reading the images doesn't really require a lot of specialized skill, and so this is a cheap alternative compared to a lot of our other screening methods.
37:42
Sonia Singh MD: And so it may be an option in low-resource settings where you cannot get some of the equipment and some of the personnel and the, radiologists and all of the stuff required to do our traditional screenings.
37:53
Sonia Singh MD: So-
37:54
Rebecca Berens MD: Oh, I'm sorry.
37:55
Rebecca Berens MD: I find this so interesting- because we are essentially turning on its head all of the potential things that would draw people to this, is like,"Oh, these are new and better technologies," and,"You're not gatekeeping me because of cost." And it's actually, the...
38:11
Rebecca Berens MD: it's not new at all.
38:13
Rebecca Berens MD: It has been studied.
38:14
Rebecca Berens MD: So this is the other thing, like people are saying they've never even tried to find anything else.
38:17
Rebecca Berens MD: They did.
38:18
Rebecca Berens MD: Yeah.
38:19
Rebecca Berens MD: And their recommendation of it is to try to do it faster and cheaper without as many humans.
38:28
Rebecca Berens MD: So I just...
38:29
Rebecca Berens MD: it's like the opposite of the reasons that people say they're looking for alternatives.
38:36
Sonia Singh MD: Yeah, all of that is true.
38:38
Sonia Singh MD: And so one of the main reasons it just kinda fell away was that there was this big study called Breast Cancer Detection and Demonstration Project, BCDDP, a large-scale, multi-center study conducted between 1973 and 1981 and sponsored by the American Cancer Society and the National Cancer Institute.
38:57
Sonia Singh MD: The aim was to evaluate the feasibility of periodically screening large numbers of women for breast cancer.
39:02
Sonia Singh MD: It had over 280,000 volunteers who were screened annually for five years with clinical examination, mammography, and thermography.
39:11
Sonia Singh MD: It's like, okay, this thing has been studied.
39:13
Sonia Singh MD: Now, granted, that was in the'70s, okay?
39:15
Sonia Singh MD: A lot of people would argue you can't even use this data because those were'70s machines and, Sure those were readers that were all human and, fallible, and now we can do it with better technology.
39:26
Sonia Singh MD: But anyway, So the sensitivity of thermography in the first two annual screenings was 37% and 44%.
39:35
Sonia Singh MD: So they actually dropped it for the remainder of the time because it was just performing so poorly, okay?
39:41
Sonia Singh MD: Now, the, there's one big paper.
39:43
Sonia Singh MD: Let me tell you the title of it, actually, in case anybody wants to really try to convince themselves of this here.
39:48
Sonia Singh MD: Let's see.
39:48
Sonia Singh MD: It has a very defiant title.
39:50
Sonia Singh MD: The paper is called Why Do Radiologists Disown Breast Thermography?
39:55
Sonia Singh MD: A Critical Review of Recent Studies and Recommendations.
39:58
Sonia Singh MD: Okay, if you're curious what the people who support thermography think this is kind of the paper that summarizes it.
40:04
Sonia Singh MD: So what they argue is that big trial where they basically were like,"Oh man, thermography is doing so badly that we just have to remove this from the study," he basically says the people who they had performing the thermography were not trained well on how to do it.
40:19
Sonia Singh MD: The people that they had reading the thermograms were not trained well on how to do that.
40:22
Sonia Singh MD: They didn't have a standardized protocol, which is one of the critiques of thermography in general.
40:26
Sonia Singh MD: And they argue that some of the sites showed good rates of sensitivity with the thermography, and then other sites where the training was poor showed poor rates, and so it diluted the results.
40:36
Sonia Singh MD: And we can't really discount it based on this one, giant trial that made it look bad, Basically, what I took from, all of this together is that the people who support this kind of make a lot of excuses for why, all the previous research is not valid and we should not base our appraisal of thermography on it.
40:58
Sonia Singh MD: To me, it's like somebody doing badly on a test and having eight million excuses to ha- for having done badly on a test, but okay, that's fine.
41:03
Sonia Singh MD: Take the test again.
41:05
Sonia Singh MD: Let's actually do the studies and prove- Yeah that it's good, and that, that just has not happened.
41:10
Sonia Singh MD: That does not- Yeah seem to exist.
41:11
Rebecca Berens MD: And I think that's a fair critique, right?
41:14
Rebecca Berens MD: It's, it is very reasonable to, to make these critiques, but like you said if we want to argue that this can replace something that has well-established data, then let's get the data to support- Yep doing that.
41:29
Rebecca Berens MD: That would be the answer.
41:30
Sonia Singh MD: I'm gonna read you a, a direct quote from this.
41:32
Sonia Singh MD: So it says, and it's describing the quality of some of this data here,"For instance, it is common for authors not to specify whether the patients were attending routine screenings or being examined due to symptoms or suspicious findings from a previous test.
41:45
Sonia Singh MD: Moreover, ambiguous labels like healthy or normal or sick and abnormal are often used without explicitly defining them." So it's pointing out very significant methodological problems- yeah in the studies that exist on this, and the, the sense I got in general was that the people who are big supporters of thermography just don't really seem to be that interested in rigorous science.
42:07
Sonia Singh MD: And I don't know if it's partially because it's fallen into this world where because no doctor or radiologist is really required for thermography it's often performed in places where there literally is no healthcare professional.
42:21
Sonia Singh MD: So you know I, as I shared with you, there's a local practice that does this, and the person who runs that practice is something called an FDNP which I don't know if you're familiar with that.
42:32
Sonia Singh MD: It has NP in it, so it sounds like they're a nurse practitioner, but it's actually a completely different degree, Let's see.
42:40
Sonia Singh MD: Let me tell you what it stands for it stands for functional diagnostic nutrition practitioner, and it takes basically 150 to 200 hours of on-demand study, and you get an online certification, and it costs between 11 and$12,000.
42:58
Sonia Singh MD: The tenets of what they do include test, don't guess.
43:02
Sonia Singh MD: So it says using functional and at-home lab kits rather than guessing or relying on standard medical reference ranges.
43:09
Sonia Singh MD: Eek.
43:10
Sonia Singh MD: The DRESS protocol, which DRESS means something different to most doctors, but it- for them, it's diet, rest, exercise, stress reduction, and supplements.
43:18
Rebecca Berens MD: Oh, Oh, minus the supplements.
43:19
Rebecca Berens MD: Yeah.
43:19
Rebecca Berens MD: Ba- basic lifestyle recommendations- I'm
43:20
Sonia Singh MD: okay with the rest of it from medical professionals.
43:22
Rebecca Berens MD: Yeah.
43:23
Sonia Singh MD: And then another tenet is no medical diagnosis.
43:25
Sonia Singh MD: They are not licensed medical doctors, and they are not supposed to diagnose, treat, or cure any specific medical diseases.
43:31
Sonia Singh MD: But, to me, I don't know how you would go for this test and not think that was there to diagnose or evaluate some kind of medical condition.
43:40
Sonia Singh MD: The whole thing sounds very...
43:43
Sonia Singh MD: It's all a contradiction.
43:44
Sonia Singh MD: Doesn't make any sense.
43:45
Sonia Singh MD: And I-
43:45
Rebecca Berens MD: Yeah.
43:45
Rebecca Berens MD: Especially when you're marketing it as an alternative to a medical test that we do use to diagnose something I don't know how this is not claiming a medical diagnosis or lack thereof.
43:57
Sonia Singh MD: They market it like that, but then there is a thing on the website that's"I am not a doctor.""I do not diagnose or treat medical disease." This is not-
44:04
Rebecca Berens MD: what size font is that in?
44:06
Sonia Singh MD: It's buried on the FAQs page- Of course but it's on there.
44:10
Sonia Singh MD: Anyway, so I think this seems to be very popular amongst a certain demographic i- in which they're exceptionally, Anti-doctor or there's no doctor involved in the situation.
44:21
Sonia Singh MD: And anecdotally I just looked up thermography in some of our big physician groups because I was like,"Oh, I'm sure somebody has posted on this and asked the opinion of radiologists and, cancer doctors and various people." And, I just saw horror story after horror story of basically patients having a breast complaint evaluated by thermography and then just not presenting to a doctor for weeks or months because they were told,"It's inflammation and you need to detox, and you just have an infection, and you need to do this protocol, and you need to do this," and then just never having evaluation by any actual healthcare professional until, it was, quite far along or clearly could've been detected earlier.
44:58
Sonia Singh MD: So anyway, that's very sad.
45:00
Sonia Singh MD: I should mention cost.
45:01
Sonia Singh MD: The cost it ranges from 150 to 300, but you can also get a full body thermography, which I f- I would imagine a lot of the people who are doing this are like,"Why not?
45:10
Sonia Singh MD: I'm already, doing it." Yeah.
45:11
Sonia Singh MD: And that's 300 to$600.
45:14
Sonia Singh MD: And I think-
45:14
Rebecca Berens MD: So that cost is not cheaper than a mammogram either.
45:19
Sonia Singh MD: No.
45:19
Sonia Singh MD: Yeah, so this is what people charge for it, but, like, how much of that is the wholesale price versus what they mark up for them providing it?
45:27
Sonia Singh MD: I don't know the answer to that.
45:28
Sonia Singh MD: Yeah.
45:28
Sonia Singh MD: So anyway, that's an overview on thermography.
45:31
Sonia Singh MD: And I think the question a lot of people would have is isn't it better than nothing?
45:35
Sonia Singh MD: Or if you're too young to get a mammogram or for something else isn't this better than nothing?
45:39
Sonia Singh MD: And I think I would just come back to okay, there's the financial aspects of it.
45:43
Sonia Singh MD: I still don't really have a great grasp of what types of false positives and what algorithm precedes...
45:49
Sonia Singh MD: what happens after you have one of these and it's not normal?
45:52
Sonia Singh MD: And I think, like I said, the, what I read anecdotally is just it seems like there's a certainly a risk of just- having something evaluated by somebody who does not know what they don't know, and therefore delays appropriate evaluation with an appropriate screening tool and a person that, can guide them.
46:11
Sonia Singh MD: Yes, so that pretty much wraps it up for thermography.
46:13
Sonia Singh MD: Do you have any closing thoughts on that?
46:15
Rebecca Berens MD: No, I think I'm good on that one.
46:17
Rebecca Berens MD: I'm, I wanna learn about QT imaging.
46:19
Sonia Singh MD: Okay, so QT ultrasound.
46:20
Sonia Singh MD: What is a QT ultrasound?
46:22
Sonia Singh MD: It is an ultrasound that is performed with your breast in a warm temperature controlled water bath, and the way they do it is they put a little pad with a little magnet on it on your nipple, and there's a table, like a massage table, and you know how there's a hole in the massage table- for your face?
46:37
Sonia Singh MD: Instead, there is a hole for your breast.
46:39
Sonia Singh MD: So you lay on your stomach, and then you dangle your breast in the hole with the little magnet on it, and then the, the magnet attaches to a thing on the other side so that it kinda, I don't know if it attaches or if it just pulls it, but it basically holds the breast in a position and tries to reduce motion, so it kinda pulls it downward and keeps it still.
46:56
Sonia Singh MD: And then the whole thing takes five to 10 minutes.
46:58
Sonia Singh MD: I don't know if that's each breast or total, but each breast gets imaged separately.
47:03
Sonia Singh MD: So there's no radiation, and then theoretically there's no pain.
47:07
Sonia Singh MD: And it gives you volumetric images and 3D reconstructions and reflection properties of the tissue that a regular handheld ultrasound cannot.
47:16
Sonia Singh MD: So this does give you more information than your typical breast ultrasound would Again, this is not new technology.
47:23
Sonia Singh MD: It was developed in the 1970s, but it was revitalized in the 2010s due to advances in technology and the speed of image reconstruction.
47:31
Sonia Singh MD: So before, there was, all these mathematical formulas that they did to do the reconstruction, and so it took a lot of time, and now all of that stuff can happen in minutes.
47:40
Sonia Singh MD: And so this is much more feasible to do on a larger scale than it was in the past.
47:45
Sonia Singh MD: Now, the vast majority of studies on this are industry funded, which again, is ironic because of this whole idea that doctors are really heavily invested in mammography and that is why they don't wanna let it go.
47:58
Sonia Singh MD: The studies on this are basically very financially motivated, so they all have to be taken with that context.
48:03
Sonia Singh MD: So there was one retrospective study which was at 108 women, five different sites.
48:08
Sonia Singh MD: Retrospective, okay?
48:09
Sonia Singh MD: And they underwent both 3D mammography and QT ultrasound within 90 days of each other, and then radiologists read both sets of results.
48:18
Sonia Singh MD: So this is...
48:19
Sonia Singh MD: Radiologists read these results.
48:21
Sonia Singh MD: It is not read just by a machine.
48:23
Sonia Singh MD: The mean non-cancer recall rate improved significantly for QT, so it was 16% lower, so meaning the number of callbacks for things that ended up being benign was 16% lower with the QT scan, and it was statistically significant.
48:41
Sonia Singh MD: There was a 2% decrease in the mean cancer recall rate.
48:46
Sonia Singh MD: So a small decrease in the sensitivity or the ability to pick it up, but then a larger decrease in the false positives.
48:54
Sonia Singh MD: So then they followed that up with a prospective study where they looked at 177 cases And they had the women have QT scans and digital breast tomosynthesis mammography two weeks apart.
49:10
Sonia Singh MD: Again the sensitivity of the QT scan was lower, so 70.6% compared to 85%, but the QT specificity was higher, so 60% versus 37%, and both of those differences were statistically significant.
49:26
Sonia Singh MD: Where QT performed a lot better was in benign cyst detection.
49:30
Sonia Singh MD: So it was able to de- detect more cysts as benign versus mammography, which kind of makes sense.
49:36
Sonia Singh MD: So important caveats to consider, nearly all this data is from manufacturer-affiliated investigators, like people who are being paid by the QT scan companies.
49:48
Sonia Singh MD: The cohorts are all small.
49:49
Sonia Singh MD: The cohorts are also disproportionately, the way they set up those groups, there were high numbers of abnormals they were not screening an average- risk population.
49:59
Sonia Singh MD: They were already starting with a high number of abnormalities, known abnormalities i- in order to try to detect something in a small group of women,'cause if you just take 100 average-risk women or 170 of them, the, the number of abnormalities is going to be so low that it's gonna be hard to prove any statistical significance.
50:14
Sonia Singh MD: So these are, like, not average samples.
50:17
Sonia Singh MD: And then they don't have any information on interval cancers, like outcomes, inter- intervals of screening, real-world performance.
50:25
Sonia Singh MD: So this, these are tiny studies in not average populations.
50:29
Sonia Singh MD: One of them was retrospective, industry-sponsored, nothing that would make us say it's time to start recommending this- for any particular population, okay?
50:40
Sonia Singh MD: Of note, QT ultrasound is FDA cleared, not FDA approved.
50:46
Sonia Singh MD: So the difference is it's cleared as an ultrasound device, not as its own independent thing.
50:53
Sonia Singh MD: So it is approved as a general breast ultrasound imaging device.
50:57
Sonia Singh MD: And then it is specifically cleared for one other indication, which is for determining the QT fibroglandular ratio which is a way to categorize breast density.
51:08
Sonia Singh MD: It is not cleared as a standalone breast cancer screening or a diagnostic test, and it's not part of any sort of screening guideline that exists anywhere.
51:18
Sonia Singh MD: So the bottom line with this is that it's very much investigational.
51:22
Sonia Singh MD: It's not a new technology, but the current state of it is a bit new.
51:27
Sonia Singh MD: We have no data on whether it changes breast cancer mortality.
51:30
Sonia Singh MD: We have no head-to-head clinical trials comparing it to, our current screening options, and there's just no real world data essentially.
51:38
Sonia Singh MD: The cost of this is 350 to 650, although again the companies that offer this, what I've observed is that it's often part of a package of all kinds of things that you can buy from them.
51:48
Sonia Singh MD: Like a test of your tears, and various other things.
51:51
Sonia Singh MD: I'm not kidding.
51:52
Sonia Singh MD: It's a thing.
51:53
Sonia Singh MD: So you know, th-
51:54
Rebecca Berens MD: We gotta do an episode on that.
51:55
Rebecca Berens MD: I'm
51:55
Sonia Singh MD: fascinated.
51:56
Sonia Singh MD: That is the starting, that is the starting cost.
51:59
Sonia Singh MD: So yeah, that brings us to the end of my talk on QT scans.
52:03
Sonia Singh MD: Do you have anything el- There, I wish there was more to say.
52:05
Sonia Singh MD: There's honestly just not that much
52:07
Rebecca Berens MD: good data to review.
52:09
Rebecca Berens MD: Yeah, I think my thing is I think both of these are illustrations of there are other technologies that have been investigated that don't have the data to support their use yet.
52:24
Rebecca Berens MD: Could we spend more money and resources further investigating these things?
52:31
Rebecca Berens MD: We could, but we already have such a good test, and I think that's the thing that...
52:37
Rebecca Berens MD: This may be the argument around this test is designed to torture women, and it's anti-feminist, and all of these things, is again, balancing the...
52:44
Rebecca Berens MD: there's lots of women's health things that need to be studied, right?
52:47
Rebecca Berens MD: Does it make sense to take limited resources to do more testing into other breast cancer screening tools when we already have really good data on the ones that we use, versus funneling that money into other underfunded understudied conditions that affect women, right?
53:07
Rebecca Berens MD: And I think that's just something that, that I'm really interested to hear someone who might have that criticism of mammograms.
53:15
Rebecca Berens MD: We have limited research funding, right?
53:17
Rebecca Berens MD: Like, where can we put it to its best use?
53:19
Sonia Singh MD: I think the counterargument to that would be, and I think this is a valid counterargument, that just historically, women's discomfort is valued so-
53:28
Rebecca Berens MD: Sure
53:29
Sonia Singh MD: poorly that it's, it has not been weighed heavily enough to- Sure.
53:34
Sonia Singh MD: Okay to drive them to look for these technologies, which I think that's a fair criticism.
53:39
Sonia Singh MD: It
53:40
Rebecca Berens MD: is.
53:40
Rebecca Berens MD: That is true.
53:40
Rebecca Berens MD: That is a fair criticism.
53:42
Rebecca Berens MD: I would also say, though, endometriosis, also severely understudied- and substantially more painful, and chronically so again, I'm not trying to say we shouldn't waste time on this, but or time and resources on this, but also there's a lot of things that we need to study.
53:58
Rebecca Berens MD: And so it just, it seems like a lower priority thing to me.
54:02
Rebecca Berens MD: Both of these are interesting, and it's not to say that if we did studies with the newer technology and the newer training and standardized protocols and all that, that we wouldn't get different data.
54:13
Rebecca Berens MD: That's very possible.
54:15
Rebecca Berens MD: But it just makes me Wonder about why to do that.
54:21
Rebecca Berens MD: But the- Yeah, so- the discomfort is, it's certainly valid.
54:24
Rebecca Berens MD: It's certainly valid.
54:25
Sonia Singh MD: Yeah, so especially with QT scans, I certainly, I don't think we can say it's definitively better or worse.
54:32
Sonia Singh MD: I just don't think we- Sure we don't know, right?
54:34
Sonia Singh MD: So maybe eventually there'll be data that show that it's better than we think, or there's a very appropriate use case.
54:38
Sonia Singh MD: It's like for women of this age who are high risk but their breasts are too dense to do these other things, this is a more appropriate tool, or this is a first step as opp- Maybe that will happen.
54:48
Sonia Singh MD: But what really frustrates me is the, the people pushing this as though it is a done deal, the science is settled, it's obviously- Yeah better, it's super- and trying to convince people to not do the evidence-based screening- Yes that does exist.
55:02
Sonia Singh MD: You're...
55:03
Sonia Singh MD: I personally think that some of these physicians, they get out there with a little bit of a contrarian view, and they see that it resonates with people and that they're being rewarded in some way for having that opinion, and they lean further and further into it.
55:17
Sonia Singh MD: And I don't think they're malicious, but I think they see that's very beneficial for them in a lot of ways.
55:24
Sonia Singh MD: And I think that if you're one of these people who believes this conspiracy of doctors wanting to, not cure cancer and wanting to create cancer patients for financial gain, again, the primary care doctor ordering the mammogram for you has zero financial interest in that, in that-
55:40
Rebecca Berens MD: Yeah.
55:40
Sonia Singh MD: In that.
55:41
Sonia Singh MD: All it does is create- Just so you don't get anything for that more work for them.
55:43
Sonia Singh MD: They're gonna have to follow it up, they're gonna have to tell you if something's wrong, they're gonna have to order the follow-up imaging.
55:47
Sonia Singh MD: So you know, that is That's one story.
55:51
Sonia Singh MD: And then if you look at the, like a QT scan, that money is going straight to the person who created the fear and offered you that product, so I...
56:00
Sonia Singh MD: There's a cognitive dissonance there that I cannot reconcile for the people who believe that argument, yeah and so yeah, I think the fault for them, I don't...
56:09
Sonia Singh MD: I support them in championing this technology and bringing awareness to it and saying,"Hey guys, we should study this.
56:15
Sonia Singh MD: We should look into this.
56:15
Sonia Singh MD: This could be-" Yeah a good alternative." Great.
56:17
Sonia Singh MD: Do that.
56:18
Sonia Singh MD: Talk about it.
56:19
Sonia Singh MD: Yell it from the rooftops.
56:20
Sonia Singh MD: But do not then go to patients and convince them not to do the thing we have good data for, and then- Yeah overstate the benefits, and act as though, it's all just so obvious and clear, and you're, you're this whistleblower truth teller.
56:32
Sonia Singh MD: Yeah.
56:32
Sonia Singh MD: And all the doctors are just too dumb to notice.
56:35
Sonia Singh MD: That just...
56:36
Sonia Singh MD: that's just, that's really hard to swallow.
56:39
Rebecca Berens MD: Yeah.
56:39
Rebecca Berens MD: No, absolutely.
56:41
Rebecca Berens MD: But yeah, it's interesting.
56:42
Rebecca Berens MD: I learned something about how these work.
56:44
Rebecca Berens MD: And again, maybe we can do more research and I'm willing to adjust my practice based on new research, right?
56:53
Rebecca Berens MD: But it's just, it makes me very concerned that this has become so prominent.
56:58
Rebecca Berens MD: And it's obviously everything you just said about the financial incentives, but it's also, it's so insidious the way this stuff spreads.
57:07
Rebecca Berens MD: And it just further feeds into the distrust of the medical community.
57:12
Sonia Singh MD: Yeah.
57:12
Sonia Singh MD: I'm glad that we now have one podcast episode out there Talking about regular old mam- two, actually.
57:19
Sonia Singh MD: Talking about regular old mammo- Yeah
57:20
Rebecca Berens MD: hopefully now when you search on Spotify"mammogram,"
57:23
Sonia Singh MD: our school- Yeah, I have a feeling our little- We'll come up
57:24
Rebecca Berens MD: there a little bit, but it's
57:25
Sonia Singh MD: probably gonna take a while our little old podcast is not gonna be able to compete with some of those other ones, but okay.
57:30
Sonia Singh MD: One
57:30
Rebecca Berens MD: day, Sonia.
57:31
Rebecca Berens MD: Let's not completely discount it.
57:34
Sonia Singh MD: So for more information on this, you can go to our Substack.
57:38
Sonia Singh MD: That's www.theantisocialdoctors.com.
57:41
Sonia Singh MD: If you want CME for listening to this episode, you can also get that as a paid subscriber.
57:45
Sonia Singh MD: And then hopefully by the time this episode comes out, this will be available for all of our episodes, but we are now producing patient education handouts.
57:54
Sonia Singh MD: So if you have a patient that comes to you with these questions or concerns about mammograms or questions about these alternatives even if you've listened to this episode and absorbed all the information, you may not have the time or bandwidth to have that full conversation with the patient, or maybe it's coming to you as a portal message.
58:08
Sonia Singh MD: So our hope is that you can use these printouts, PDFs, as an additional resource to start a conversation and give them some quick info.
58:17
Rebecca Berens MD: Yeah, and if you're a patient listening to this or, a non-medical professional I think it would be really a good summary,'cause the pod- the Substack posts get long.
58:27
Rebecca Berens MD: Yeah.
58:28
Rebecca Berens MD: I can see that becoming a, a TLDR situation, and so this will at least give you the hit points if you're like,"I don't have time to read that whole podcast.
58:35
Rebecca Berens MD: I don't have time to read this whole article.
58:37
Rebecca Berens MD: Let me just get the basic summary on a one page." And yeah.
58:41
Rebecca Berens MD: So hopefully it's useful to people.
58:42
Rebecca Berens MD: I hope so.
58:42
Sonia Singh MD: Or if you're a patient with a family member or friend who, you're trying to convince"Hey, no,""please get your mammogram." Those things are not good alternatives.
58:49
Sonia Singh MD: Hopefully this would be, like, an easy resource for that person too.
58:52
Sonia Singh MD: 'Cause that person, if they're not really skeptical of it, is probably not gonna listen to our hour-long podcast conversation, and may not get through the entire Substack post.
59:00
Sonia Singh MD: But maybe a one-pager with Yeah just the facts would get them there, yeah.
59:03
Sonia Singh MD: All right, Rebecca, I know you got a patient, so you gotta go, so I'll let you go.
59:05
Sonia Singh MD: Thanks.
59:06
Rebecca Berens MD: Yeah, thanks.
59:07
Rebecca Berens MD: Bye.
59:08
Rebecca Berens MD: Bye.
59:10
Sonia Singh MD: Hey guys.
59:10
Sonia Singh MD: Last but not least, we have a very important disclaimer.
59:14
Sonia Singh MD: This podcast is intended for educational and entertainment purposes only.
59:18
Sonia Singh MD: The content shared on this podcast, including but not limited to opinions, research, discussions, case examples, and commentary is not medical advice and should not be considered a substitute for professional medical evaluation, diagnosis, or treatment.
59:33
Sonia Singh MD: Listening to this podcast does not establish a physician-patient relationship between you and the hosts.
59:38
Sonia Singh MD: We are doctors, but not your doctors.
59:41
Sonia Singh MD: Any medical topics discussed are presented for general informational purposes and may not apply to your individual circumstances.
59:48
Sonia Singh MD: Always seek the advice of your own qualified healthcare professional regarding any questions you have about your health, medical conditions, or treatment options.
59:55
Sonia Singh MD: Never disregard or delay medical advice because of something you've heard on this podcast.
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Sonia Singh MD: While the hosts are licensed physicians, the views and opinions expressed are our own and do not represent those of our employers, institutions, organizations, or professional societies with which we are affiliated.
1:00:12
Sonia Singh MD: Although we do our best to stay up to date, please note that this podcast includes discussion of emerging research, evolving medical concepts, and differing professional opinions.
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1:00:40
Sonia Singh MD: Thanks again for joining
1:00:42
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