Dorothy: [00:00:00] Dr. Wei Yang is a professor and the Robert D. Moreton Distinguished Chair at The University of Texas, M.D. Anderson Cancer Center. She is a fellow of the Society of Breast Imaging and also a fellow of the American College of Radiology. She’s a member of the Senior Women’s Leadership Network under the Diversity, Equity, and Inclusion Workgroup at MD Anderson, and she is passionate about supporting academic growth for women and minority teams. Dr. Yang has a unique way of describing radiology and a unique way of describing dense breast. During this episode, we talk about the different kinds of screening, the importance of screening, and the importance of having it at the recommended age. Dr. Yang also discusses the role of artificial intelligence in medicine and explains why we should not fear it. Lastly, we finish with her message to women, which will leave you inspired and empowered.
[00:01:00] Let’s Talk About Your Breast, a different kind of podcast presented to you by The Rose Breast Center of Excellence and a Texas treasure. You’re going to hear Frank discussions about tough topics, and you’re going to learn why knowing about your breast could save your life.
Dr. Yang, thank you so much for being with us today. We just, are so excited about having you on this podcast. And would you tell our listeners just a little bit about you?
Dr. Yang: Absolutely. It’s my pleasure to be here this morning, Dorothy. So, I’m originally from Singapore and, uh, I’m one of three children to my parents who were both originally from Shanghai and were first generation immigrants to Singapore.
They were post, uh, World War II babies, so they grew up in abject poverty. Um, but I think they, they worked really hard and ensured that the three of us had, um, every opportunity for education. And so, um, I think the entire family, uh, is a family of physicians, bar my [00:02:00] mother, but she is really the matriarch of the family that kind of keeps us whole and keeps us very curious about things that are new in life.
Dorothy: How interesting. And when did you come to the States?
Dr. Yang: I arrived in the United States exactly six weeks after the major event 9/11.
Dorothy: Oh my gosh.
Dr. Yang: Yep. And so I’ve been here for more than two decades and it is quite a marvelous country.
Dorothy: You said all of them are physicians? All your siblings are physicians?
Dr. Yang: Yes.
Dorothy: So, um, And what specialties?
Dr. Yang: So my sister is a gastroenterologist. Yeah. And, um, her husband is, um, a, uh, GI surgeon, and my brother and his wife are both general family practitioners, and so was my dad. And I think the, the other extended factor here is in the Asian culture, as you are growing up, you don’t really have much of a choice in terms of your vocation. You are told that you can choose one of three, which is either medicine, law, [00:03:00] or engineering.
Dorothy: Oh, really?
Dr. Yang: Yeah.
Dorothy: Wow.
Dr. Yang: Interesting, but the kids of this generation, all of our children, I don’t think they subscribe to that same ideology, so we’re moving with the times.
Dorothy: Right. Are your siblings here in the United States?
Dr. Yang: No. They’re both in Singapore.
Dorothy: So you make many trips back?
Dr. Yang: At least once a year.
Dorothy: At least once a year. Yeah. So why did you choose radiology?
Dr. Yang: Yeah, that’s a 64 million question. I was growing up and I was just hanging out with everyone and my brother and sister. I think I was the most timid in terms of being brave enough to handle the trauma of disease and illness and being the front line individual.
Uh, and I thought that Radiology really fit my, my, uh, special interests. It’s very much pattern recognition. It’s a lot of organization, but you really assist the entire team by putting things together behind the scenes. So we spend, uh, our days, um, looking at images and we [00:04:00] are looking for evidence of disease and we have to be very conversant with what is normal. And I think that, uh, a well trained radiologist is always able to put a story together of, you know, how this patient got to where he or she is.
Dorothy: Oh my goodness. And, and you, you have a very definite interest in breast radiology. Yes.
Dr. Yang: Yeah.
Dorothy: And that’s your fellowship?
Dr. Yang: That is also a very interesting story. So, um, I was British bordered. And at that time, after having completed my examinations with the Royal College of Radiology, once again, back in, um, in Asia and Hong Kong, my boss then said, you know, um, there are many opportunities for you. You could look at being a musculoskeletal radiologist and neuro radiologist and abdominal radiologist, but I would like you to do breast.
And I almost fell off my chair because that was like, not really front in line because the, Breast cancer was not as common in [00:05:00] Asia at the time that I was training. Nonetheless, he said, you know, I would like you to take this on. And there I was, an intrepid explorer, working together with the surgeons and, uh, the other medical oncology teams. And this is where I am.
Dorothy: You know, that is fascinating. What a wise suggestion from him. I mean, he must have seen something.
Dr. Yang: Yeah, I think he felt like women’s health was, uh, becoming more and more front and center. So that was a really great opportunity.
Dorothy: Right. Now talk to us about the different screening modalities and, breast cancer and in diagnosing breast cancer. I think many of our listeners sort of kind of know mammography is needed or a mammogram once a year is good, but tell us about the other things that have really made a difference in diagnosing breast cancer.
Dr. Yang: Absolutely, so I think for everyone who’s listening today, the most important take home message is that mammography saves lives, and [00:06:00] our recommendation is that mammography once a year from age 40 for a woman at average risk is critical.
In terms of other modalities that are currently available, digital breast tomosynthesis, which is similar to a mammogram, is, uh, an additional tool that is available. Breast ultrasound is something that is used largely in other countries in other parts of the world due to the lack of mammography equipment.
And I think last but not least, one of the more advanced imaging modalities is breast MR. And this is a very powerful tool that Um, by far and large has, uh, exquisite anatomical detail, so it is most, um, appropriate for screening of women who are at elevated risk. It’s been shown to be highly advantageous.
Dorothy: Okay. I have about 10 questions here. [00:07:00] Uh, you said tomosynthesis, and, you know, we talk about that all the time. We know that’s 3D mammography. But give us an example. Is it like our old pictures that we used to take with a camera and have to get them developed compared to our digital images that we have today on our phone? Is that a good analogy?
Dr. Yang: Absolutely. So, um, a regular 2D mammogram has four images taken of both breasts. Each breast will have two views during a screening mammogram. The difference, um, between a regular 2D mammogram and a, uh, digital tomosynthesis is that the mammogram machine takes multiple small images at different angles through an arc as the machine moves through the breast. And then these images are then reconstructed for the radiologist like myself to review. So instead of reviewing a single image, the attending radiologist may go through [00:08:00] between 50 to 60 to 70 images using a CINI format. So the advantage here is to provide, uh, an additional way of spreading out dense breast tissue because of the reconstruction of with two potential advantages.
One is to unmask any new lesion that’s growing or embedded within an area of dense tissue. And the other is to allow the interpreting radiologists to discern that what may appear as a pseudomass It’s nothing more than overlapping breast tissue, as you scroll through this like a stack of cards.
Dorothy: So sometimes we absolutely have to do a diagnostic mammogram just to make sure on that, but not as many as we used to with 2D.
Dr. Yang: That’s the goal. And I think, um, best practice is that for 10 women who come from screening. Not more than one would be called [00:09:00] back for diagnostic work. So that is reassuring in, in terms of, it’s not a common occurrence. It does happen, but it’s infrequent.
Dorothy: And for our population, having to make multiple trips many times is just such a hardship, particularly because we serve so many counties.
Dr. Yang: Absolutely.
Dorothy: And if they have to come back to us, it’s, it’s really uh, difficult many times and it’ll be delayed and, you know, so. It’s so important that women understand this is, this is a better mammogram any way you go. Now, when you talk about MRI and high risk, explain to us what high risk means.
Dr. Yang: Yes. So the American College of Radiology defines high risk as a woman who has a lifetime risk of more than 20 percent for developing breast cancer. And there are many risk models that can calculate that risk based on, um, all the information that is pertinent to a woman. Does she have a family history of breast cancer defined as a first degree relative, [00:10:00] a mother or a sister with breast cancer? What age was the cancer of the relative diagnosed?
Does the woman have a genetic mutation? which is a test that’s done, uh, for, um, patients who develop cancer young or who have a strong family history. And there is a whole cadre of additional risk factors that can become quite complex but are incorporated in different risk model calculations.
Dorothy: And when an MR is ordered, um, there’s many different reasons for ordering it.
Dr. Yang: Yeah.
Dorothy: But it gives a very definitive. Uh, we, you know, look at the breast or?
Dr. Yang: Yeah. So it’s, uh, it’s a great question that you pose, Dorothy. So in addition to high risk, there are other groups, um, patients who’ve received mantle radiation for lymphoma, particularly in the region of the chest due to the extended radiation. Uh, that’s another, another uh, group. And I think other [00:11:00] women that have had multiple breast biopsies with high risk lesions, and they fall into this risk category. I think that there is an evolving narrative out in our community. The breast imaging team is also very interested in understanding the value of breast MR for women who’ve already had a first breast cancer event, and who have dense breasts, will MR be valuable in surveilling, you know, the breasts that are still in place.
Dorothy: And a lot of women have dense breasts. It’s very, uh, confusing, I think, when we talk about dense breasts to, to women, they— That doesn’t even make sense to them.
Dr. Yang: Yep. So I think we define breast density as, uh, how it’s seen or measured on the mammograms. And, um, when you look at a mammogram, basically, everything that is non dense appears darker. [00:12:00] And that’s usually the fat that we have in the breast that cushions the breast. And everything else, the breast tissue, the connective tissue, appears as white. And that accounts for the breast density.
Unfortunately, when a lesion is growing, that also appears as dense and, you know, white, if we use a binary descriptor for the mammograms. So, um, the beauty of MR is that, um, density doesn’t play a role in how MR grows. discerns or reveals a cancer because to a large extent, it also depends on the contrast that’s administered and it’s predicated on the, um, the tumors that are very hungry for vessels and so they light up as we give contrast.
Dorothy: Ah, good explanation.
Dr. Yang: So in many ways, MMR in many ways overcomes the, the breast density.
Dorothy: As a, a breast radiologist, you do interact with patients a lot. That was not what you intended going in, right? And, and [00:13:00] what do you find most often that women ask?
Dr. Yang: Um, I think the most, as, as I’ve looked, um, back over the, the two and a half decades, the, the most important thing that women want to know is what the, what they should know and what they don’t know.
So I think that even for a woman who comes for screening, my sister was a gastroenterologist, she’s not clear about screening guidelines, you know, as to when she should or should not do. So I think first is clarity of guidelines and recommendations. So once again, I just want to stress that our guidelines is annual screening mammograms for every woman starting at the age of 40.
For a high risk woman, they should speak to their physician to gauge their level of risk to determine whether additional screening modalities are of benefit and at what age they should start screening. In terms of what a woman would like to know [00:14:00] is, as long as the screening mammogram is normal, they’d rather just come in and go out. Which I think is the correct thing, because all screening modalities should be low cost, should be of little interruption to the daily walk in life. So we, we don’t really want more women to be disturbed. And it’s only when the mammogram is abnormal that questions arise. What should I expect next? What workup like? Should I have a mammogram, or will I have a mammogram and ultrasound, and will I need a biopsy? So I look at that as the first capsule for an abnormal mammogram, and it is by all measures a woman’s worst nightmare to get that little letter that invites them for more work.
The good news, as we’ve talked about this, is for, um, remember we talked about this, that of 10 women who undergo screening, not more than one should be called [00:15:00] back. And for the majority of the callbacks, the good news, it’s, it’s just normal tissue or something that’s not of concern. So that’s also very reassuring.
The second point women I think would like to hear is that if the mammogram is abnormal, if there is a lesion, if a biopsy is needed, and if a cancer is diagnosed, If cancer ever is to be diagnosed, that is the way that we would like a cancer to be diagnosed, because it is small, it is eminently treatable, and all the treatment options available for women today, Um, have very good outcomes.
Dorothy: Yes.
Dr. Yang: So there is a high likelihood that the woman adequately treats it will be able to get back to normal life and carry on with all her normal responsibilities.
Dorothy: Right, right. That is the most encouraging thing about screening and continuing to do it annually.
Dr. Yang: Absolutely.
Dorothy: [00:16:00] Now, in the women that we diagnose, we’ve, uh, been watching, but in over the last eight years, unfortunately, all those that we have diagnosed at stage four we’re uninsured. And, you know, that speaks to me to the, to what we need to do to be sure that our uninsured women have those advantages. As every woman because when it gets to stage four, it’s a very different animal.
Dr. Yang: So dorothy that’s something that is really close to my heart. And I think that um What The Rose is doing and what many other organizations is doing is something that um, I think it’s wonderful the first advantage, um, you know using this platform and all others is to consistently message to every woman out there hearing that A cancer that is diagnosed early with screening is eminently treatable and allows the woman to go back to her normal routine.
An [00:17:00] advanced cancer, where it’s something that you feel or, you know, it’s something that declares itself, is still treatable, however, the outcomes are different and the treatment pathway becomes much more complex. So there may be different ways of treating, you know, you might have to, um, use all of them. Yep. Surgical treatment, radiation, medical treatment. So we really want to bring that, um, needle down the path to earlier diagnosis where the treatment is simpler and less complex.
Dorothy: What keeps you in this for two and a half decades?
Dr. Yang: Um, I think that, um, I really have to talk about the patients. you remember that as a young girl, I was really very timid about, um, illness and outcomes related to that. I think what I’ve seen is the, um, the enduring spirit of every patient who has been diagnosed with cancer, and this is not [00:18:00] just breast cancer, and how their, uh, their dignity and spirit, their perseverance, their compassion even for the providers, as you’ve mentioned, right? Women often put themselves at the end of the healthcare line, but I’ve been so touched by hordes and hordes of patients who are tremendously ill, and they still take the time to care about providers, you know, to inquire about us, how are you? And that in itself, is, um, a rallying flag. It’s, it’s what makes all of us get out of bed and come to work.
Dorothy: Right.
Dr. Yang: Yeah, I cannot overemphasize that.
Dorothy: And you’re a little bit of a technology geek, aren’t you? I mean, I know you’re interested in all new things. How do you see mammography going in the next few years?
Dr. Yang: Yeah, the short qualifier is I’m technologically illiterate. My son is into technology, but I think what I am curious about is what is [00:19:00] available for us and how we evolve as technology innovates. And I feel that’s something that is for us to use to our benefit. For example, in breast imaging, we have talked about, um, technologies with mammograms, with ultrasound, with MRI.
I think what is very new today is contrast enhanced mammograms, which is administration of intravenous iodinated contrast. And the woman can have that done at the same sitting as her workup. So, that’s another evolving technology that I think we want to get to know more about. There is a lot out there about artificial intelligence that we know, and yet we don’t know enough about, but we know enough to know that that is going to be a huge advantage for all of radiology, if not all of industry.
So, the question for us is, how can we use it in a responsible manner? How can we use [00:20:00] it to benefit the patients and benefit the workforce? How can we use it to address burnout? How can we use it to elevate the women who are at highest risk, or at Uh, at highest risk in a, in a whole day’s work, the work list of maybe 250 exams.
So I think those opportunities are out there and those are things that together we want to explore and bring into the work stream.
Dorothy: And you’re not, afraid of this AI introduction into medicine?
Dr. Yang: If you remember, my mom was the only non physician, but I think it was her curiosity that actually battled fear. So if you think about it, the, the, the opportunity can be used and co opted into deriving more benefit. Um, yeah, I don’t really understand the word fear in terms of new technology. I think it’s, it’s something that allows us to discover more and bring the greater good. [00:21:00]
Dorothy: Now you are entering into a primarily male field. Did you ever feel extra pressure because you were a female going into this, this field?
Dr. Yang: I think I’ve been really fortunate, Dorothy, as you were asking me that question. I think in my journey, um, with every organization that I’ve worked and for every leader that I’ve worked with and under, I’ve been given the privilege and I’ve been taught to look at the specialty for the specialty’s purpose and the specialty’s value and, um, not focus on that as, you know, um, as an asymmetry. Yet I recognize that there always is asymmetry in every aspect of work. So I’m, I’m pleased to, to say that, um, in, in the work areas that We are, [00:22:00] we, we are very open, you know, to discussing issues and to finding opportunities to reduce asymmetries wherever we, we encounter them.
Dorothy: And to reduce those imbalances.
Dr. Yang: Absolutely.
Dorothy: To reduce that, uh, conflict or that, yes.
Dr. Yang: Absolutely.
Dorothy: It’s just a different level.
Dr. Yang: Yeah.
Dorothy: Than many other professions.
Dr. Yang: Yeah.
Dorothy: The, uh, what, what do you feel like, and, and I know we’ve talked about the technology part, but what do you feel like as a physician is the most important thing you can do to support that patient?
Dr. Yang: Um, I think—
Dorothy: Maybe not just as a physician, maybe as a person.
Dr. Yang: Absolutely. Yep. I think that, um, in our specialty, because we are actually patient facing and front line facing and, um, half if not more of our work involves intervention. And intervention is not just a procedure, but intervention as in speaking to a patient. [00:23:00] For example, you talked about, uh, what might be a woman’s greatest fear, what they need to know. I think breaking the news that, uh, A woman has just been diagnosed with cancer is something that we cannot stop learning how to do differently or better. That’s number one. So, connection with the, um, the woman who is the person that you’re reading the mammograms of or doing the procedure or communicating result with is important.
Um, Walking that journey with that patient through what to expect next, uh, in terms of meeting with the cancer panel or the cancer experts, what might that journey look like during surgery? How long might it be, what does medical treatment comprise of, what to expect, what might radiation treatment be like, and you know, what to expect after that as a survivor.
So [00:24:00] the um, advantage of today’s um, technology is multidisciplinary teams now learn how to work together. You asked me about, you know, opportunities, and when multidisciplinary teams come together, my strong belief is that the woman is the beneficiary.
Dorothy: Oh, absolutely.
Dr. Yang: Because we don’t have conflicting opinions, we have consistent messaging, and a patient is always very keen to know, what should I expect, and where will I land, what is my final destination? I think it’s equally important to share with the woman that it’s probably easier to take things one step at a time, against our strongest reflex. We really want to get to the end and we want everybody to say that is exactly how it’s going to be and it’s going to be all right and okay. And I think what I’ve seen in the years is that sometimes it’s equally important to say it’s all right and it’s [00:25:00] okay right here. Regardless of how difficult it is.
Dorothy: Right.
Dr. Yang: Because that’s the best that we can do at that step of the diagnosis and the next step of preparing for the treatment. And I think that’s about the best that we have enough resources for. To take care of for that day.
Dorothy: And she, the women, you understand that. Do you feel like, I mean, you are delivering this diagnosis. Most of the time. Some of the time.
Dr. Yang: Yeah. There are days where I feel very unqualified to answer that question in complete authenticity, Dorothy, because I think that, um, it’s very important to understand that it, it only makes sense to a woman when the speaker has gone through it completely.
Dorothy: Oh.
Dr. Yang: Yeah. So I, I kind of can share with them that this is where I am with you right now at the diagnosis [00:26:00] and you know, with everything that needs to be done, sometimes it’s more than one intervention. And I also want to prepare the journey ahead so that they get the best advice from their medical specialists. So, I’m just giving a very broad summary, but prepare them for meeting with their oncologist so that they hear it fresh, and they hear it from their primary treating physician’s perspective.
Dorothy: I’m sure that knowing that it’s okay to ask questions is so important. Many of our patients will not question, and they leave not knowing. You know, it’s, it’s, uh, it’s very difficult. When, especially when you’re dealing with many different populations, that English is not their first language. And that’s one of our biggest challenges.
Dr. Yang: Yeah. So I think from, um, from that perspective, it’s, it’s something that we do every day. We provide a very clear summary of what it [00:27:00] looks like. And, um, we, I think we also break it down into the different segments. Because I think that journey through breast cancer is not a marathon. It’s, it’s kind of like a, a long trek, you know, it’s not a sprint.
Dorothy: Right. And that’s so important for women to hear. Also to know that not everything is laid out. Not everything can be planned. And there’s so many different, um, uh, you know, paths that you may need to go to. But I think when you prepare that woman for, here’s where we are, And here’s what we can do. And usually it’s the caregiver with the woman when, when she’s getting this news.
Dr. Yang: The majority of women have, um, a caregiver, a relative, or a friend. I don’t think it is, uh, a hundred percent. And I think, um, you bring up a very important point, because when, um, the [00:28:00] news is discussed, it’s always, um, a prep question as to whether this is a good time to talk about this.
Dorothy: Oh.
Dr. Yang: Yeah. I think, because you don’t really want somebody who is caught off guard or, um, not in a good position. It’s sort of not in a good frame. So I, I think having a caregiver or a friend present is something that we, we definitely encourage.
Dorothy: Yes. So now coming from your background and knowing the difficulties that can exist in the world, what is it you hope for your children?
Dr. Yang: Um, both of them are not in the medical field and I will share that they, are very fearful of things when it comes to medicine. I think that my, my hope for them is that they will find their passion and they will find a really good place to park their passion and they will give their best and their all. I think they’ve been very blessed with, um, [00:29:00] faculties with abilities and I hope they will use that for service in the decades to come.
Dorothy: Right. And that’s really what your parents were telling you in a way.
Dr. Yang: Yeah, I think my parents, um, As, as I’ve had the chance to reflect on after, after the pandemic, I think, I think they were, Um, salt of the earth, um, middle class parents who instilled in us very strong values, very strong work ethics. Um, I think that they have been huge role models in how, um, a parent walks through, you know, life’s journey with their children. And I think parenting is one of the toughest, toughest jobs on this earth that is not really— That’s not recognized in big ways and small, but most of all, I think they teach us also how to live with ourselves, learn how to forgive ourselves. I think this is something that’s an important tool.
Dorothy: Oh, that’s good.
Dr. Yang: Yeah. Forgiving self allows us to [00:30:00] see things in a broader perspective and be there and available for our patients and our women, you know, who, who are seeking assistance from us in, in more ways than one.
Dorothy: So do you have anything else that you’d want a patient sitting with you to know?
Dr. Yang: I would like them to know that, um, they are of tremendous value. Their life really matters. And if they come and get their annual checks, that is that one big way that they can start to be a value to their own community. Because I think health is something that we all take for granted in big ways and small. And I think coming for your screening exam is One of the best ways to combat the, the different pathways in which disease can kind of declare itself.
Dorothy: Wow. Great advice.
Dr. Yang: Yeah.
Dorothy: Thank you again for being with us. This was such, such interesting knowledge to, to know about and for your [00:31:00] really wise advice to women. Don’t put yourself last. Have your annual mammogram and you are of value.
Dr. Yang: Thank you, Dorothy. I really enjoyed this and always enjoy speaking with you and learning from you.
Dorothy: Thank you.
Dr. Yang: Thank you.
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