[00:00:00.008]
Welcome to this edition of AMC.

[00:00:01.870]
Tell you how I got better. I'm glad to be

[00:00:03.879]
here, but a mission

[00:00:06.269]
to. Well, I think that we're, we're talking, we're gonna

[00:00:08.398]
talk about everybody's Arkansas is

[00:00:10.720]
the 2nd highest prescriber.

[00:00:15.189]
Welcome to AFMCTV. I'm Robin

[00:00:17.190]
Ledbetter. Thank you for joining us. Today I have

[00:00:19.190]
with me Doctor Steven Routon, and he is a board

[00:00:21.429]
certified radiologist specializing in breast

[00:00:23.658]
imaging at Carti.

[00:00:25.010]
Doctor Routton, thanks for being here. Thanks for having me. So

[00:00:27.388]
we're talking about contrast

[00:00:29.719]
enhanced mammography. Tell us what

[00:00:31.899]
that is and how is it different from traditional

[00:00:33.990]
mammography. For lack of a better term, it's

[00:00:36.179]
a better mammogram. So mammography

[00:00:38.270]
is the gold standard, and it has

[00:00:40.298]
been, uh, I think it will be going

[00:00:42.590]
forward in the future for breast cancer screening.

[00:00:45.079]
Contrast is just an an add-on to it.

[00:00:47.240]
So, um,

[00:00:49.200]
any woman who's gotten a mammogram before

[00:00:51.279]
won't notice much different except the

[00:00:53.679]
before, where it's just a small

[00:00:55.959]
IV and, and a little contrast

[00:00:58.158]
injection and then we do the standard

[00:01:00.189]
mammogram view. So it allows

[00:01:02.298]
us to see a little bit more, enhances

[00:01:04.959]
our detection and and helps a

[00:01:07.000]
certain subset of women who who may benefit

[00:01:09.230]
from a little additional screening besides just your

[00:01:11.448]
standard mammogram.

[00:01:13.150]
And this is new to Cartai.

[00:01:15.000]
Why has the practice started

[00:01:17.489]
um implementing this type of mammography?

[00:01:19.739]
Yeah, so it's new to Cartai, and we're the

[00:01:21.819]
first in the state to implement it. So,

[00:01:24.088]
um, right now we're, we're offering it at two

[00:01:26.180]
centers, um, our breast center in

[00:01:28.260]
Little Rock and in El Dorado,

[00:01:30.540]
and we'll likely be expanding that, um.

[00:01:32.980]
Uh, in the future.

[00:01:34.379]
Um, it's, it's a newer technology. It's,

[00:01:36.579]
it's not brand new, it's been on the market, it's

[00:01:38.579]
been FDA approved, um, and,

[00:01:41.120]
and anytime anything comes out,

[00:01:43.230]
there's gonna be a little lag time and

[00:01:45.379]
just for us to get to know it too and

[00:01:47.418]
see, and I've been searching for these,

[00:01:49.739]
you know, additional modalities

[00:01:51.819]
and and things that might just offer

[00:01:53.900]
the absolute best for patients.

[00:01:56.790]
How does the contrast agent enhance

[00:01:58.790]
the imaging process? What type of lesions

[00:02:01.028]
or conditions does it help reveal?

[00:02:03.189]
So, you know, contrast isn't new. It's

[00:02:05.549]
it's new to mammography now with this, but it's

[00:02:07.629]
not new to imaging. So a lot of people have had

[00:02:10.479]
CT scans or CAT scan and and

[00:02:12.639]
gotten a contrast injection or or

[00:02:14.679]
MRI's of of any part of the body

[00:02:16.830]
and and typically contrast is involved

[00:02:18.879]
there. What it does is

[00:02:21.080]
contrast is taken up by different parts of the

[00:02:24.038]
body, um, a little bit more

[00:02:26.149]
and can show up. It enhances, um,

[00:02:28.479]
the, the image quality.

[00:02:30.278]
And so the the

[00:02:32.360]
science behind that with with mammograms

[00:02:34.520]
are that masses in the breast and some

[00:02:36.758]
some forms of growth.

[00:02:38.338]
Can take up more contrast and they show up brighter

[00:02:41.020]
on the mammogram.

[00:02:42.219]
You typically what we've been looking for on the mammogram

[00:02:44.419]
is just

[00:02:45.788]
masses and calcifications and things that

[00:02:47.838]
stand out and things that change over time.

[00:02:51.139]
This contrast allows us to look and say, hey,

[00:02:53.538]
what might be more active in taking

[00:02:55.659]
up that contrast?

[00:02:57.508]
And how long does does this entire procedure

[00:02:59.659]
take? Is it something that's super quick in

[00:03:01.669]
and out or does it take a little longer? Just a

[00:03:03.689]
little bit longer than the standard mammogram. So

[00:03:05.969]
most appointment times you'll probably be in and out

[00:03:08.020]
in about a half hour. So, you know,

[00:03:10.849]
and, and like I said, it's the

[00:03:12.939]
same. So most women that have had a mammogram

[00:03:15.330]
before aren't gonna notice much different once we

[00:03:17.419]
get to the X-ray picture side.

[00:03:19.229]
Uh, the same compression, the same mammogram,

[00:03:21.460]
if they've been to car town it'll be the same room we've we've

[00:03:23.538]
done it in. It's just beforehand we start

[00:03:25.659]
that IV. The contrast injection goes

[00:03:27.819]
pretty quickly, and then afterwards we

[00:03:29.860]
just observe for a few minutes just

[00:03:31.969]
to make sure everything's fine and

[00:03:34.020]
no one has a reaction to it.

[00:03:36.618]
And is this for women that have dense breast

[00:03:38.929]
tissue, or does that matter? Yes.

[00:03:41.258]
So, and

[00:03:42.659]
with, with any new screening, I'll tell people

[00:03:44.860]
that not everybody is going

[00:03:46.889]
to need that.

[00:03:48.028]
Yes, uh, we have certain patients that

[00:03:50.149]
need what's called supplemental screening. And, and

[00:03:52.349]
so like I always reiterate

[00:03:54.469]
that mammography is the gold standard. And, and I

[00:03:56.629]
say that to say that

[00:03:58.710]
one of the misconceptions I

[00:04:00.719]
always want to fight when there's new technology is

[00:04:02.788]
to say the old one isn't bad. So,

[00:04:04.990]
mammograms are still the gold standard, the 3D

[00:04:07.189]
mammograms, we do those on everyone at Carti.

[00:04:09.830]
You're always,

[00:04:10.949]
always gonna get those.

[00:04:12.520]
Um,

[00:04:13.558]
with the contrast, we offer it

[00:04:15.558]
to a certain subset, so not everyone will,

[00:04:17.959]
will need that. Yes, women with dense breasts,

[00:04:20.838]
um, will qualify for this type of

[00:04:22.879]
screening and,

[00:04:24.079]
and, uh, women that are high risk. So

[00:04:26.278]
some women that, that have elevated risk

[00:04:28.319]
factors, maybe they've had genetic testing

[00:04:30.470]
or they've had, um, previous

[00:04:32.959]
biopsies that were abnormal or family

[00:04:35.160]
members.

[00:04:36.165]
Um, or even women will use it in the

[00:04:38.213]
diagnostic setting for some women that have

[00:04:40.295]
newly diagnosed breast cancer that we might stage

[00:04:42.653]
disease. So there's a lot of utility

[00:04:45.173]
that, yeah, some some of our patients may not

[00:04:47.415]
necessarily need it, but we are gonna have a lot that that

[00:04:49.894]
are gonna qualify.

[00:04:51.774]
And how does the sensitivity and specificity

[00:04:53.963]
of CEM

[00:04:56.134]
compared to an MRI or an ultrasound?

[00:04:58.535]
It's very comparable to MRI.

[00:05:01.369]
And, and it's, it's better than that of ultrasound.

[00:05:04.220]
And so, yeah, the sensitivity is more

[00:05:06.290]
so over 97% of, of breast

[00:05:08.500]
cancers are gonna be detected,

[00:05:10.100]
uh, by this. And so

[00:05:12.259]
that's the first thing we always talk about. And and

[00:05:14.298]
with any imaging modality, right? If

[00:05:16.420]
someone has breast cancer, we want to find it

[00:05:18.819]
and we want to find it early and this helps

[00:05:20.819]
us. The thing I like about this

[00:05:23.100]
too is that the specificity

[00:05:25.619]
is also very high.

[00:05:27.699]
And so,

[00:05:29.269]
That's also the other thing I'll say that most

[00:05:31.269]
of my patients thankfully are gonna be normal and

[00:05:33.389]
they're not gonna have breast cancer.

[00:05:35.389]
And that being said, I wanna be I wanna be confident

[00:05:37.670]
that they're normal and not have to work up

[00:05:40.588]
findings that may be just inconsequential

[00:05:42.720]
to the patient. So that's why I really like this,

[00:05:44.769]
not just to be able to detect things, but

[00:05:46.939]
to be able to say, hey,

[00:05:48.470]
when we're comfortable with the mammogram, we're

[00:05:50.509]
not seeing anything, we know that that

[00:05:52.548]
our patients are OK.

[00:05:54.160]
Other side effects? Do you see things

[00:05:56.439]
that um are a little bit different than say,

[00:05:58.920]
other contrast type imaging?

[00:06:01.480]
The the main side effect to worry about is if

[00:06:03.519]
anyone has a history of an allergic reaction

[00:06:05.548]
and and a lot of people will know

[00:06:07.559]
that because

[00:06:08.559]
like I said, people have,

[00:06:10.160]
many people have had contrast just from a CT scan

[00:06:12.600]
or an MRI. So that'll that'll probably be our

[00:06:14.798]
our first question that we ask people, Have you ever

[00:06:16.838]
had a reaction?

[00:06:17.988]
And, and tell us what it is, because there's

[00:06:20.000]
various different types of reactions. So

[00:06:22.329]
the, the main one is a contrast allergy.

[00:06:24.639]
The other things that are just side effects and and I've

[00:06:26.759]
had contrast, so I, I can speak to it is,

[00:06:28.920]
um, you may feel just a warm sensation

[00:06:31.170]
when it goes in and that that goes away

[00:06:33.238]
in a few seconds, and some people report a little metallic

[00:06:35.639]
taste in their mouth. Those are, I mean,

[00:06:37.879]
those are usually done by the time the exam's over.

[00:06:40.559]
Should patients with like kidney issues or

[00:06:42.720]
allergies, you mentioned that about allergies and

[00:06:44.798]
watching that with the contrast. Is there other

[00:06:47.199]
issues that you will look for or

[00:06:49.230]
they should be concerned about? Mainly, mainly

[00:06:51.278]
allergies and then, yes, uh, renal

[00:06:54.309]
issues and

[00:06:55.399]
so we, we may, um,

[00:06:58.040]
we may check if you've had labs recently or

[00:07:00.040]
we can can run a quick one just to check your renal

[00:07:02.160]
function and make sure it's OK and that you qualify.

[00:07:05.170]
And you have some success stories, um,

[00:07:07.459]
cases where CEM has made a difference

[00:07:09.579]
in early diagnosis or treatment planning.

[00:07:11.899]
Right now, uh,

[00:07:13.858]
because we haven't done many cases, uh,

[00:07:16.338]
the success stories really are on that,

[00:07:18.928]
that negative predictive value, that

[00:07:21.059]
that specificity where we've worked up some patients

[00:07:23.338]
that Had some findings that showed up

[00:07:25.470]
on imaging and and sometimes the ultrasound

[00:07:28.149]
can look a little suspicious so the mammogram

[00:07:30.298]
changed there are a lot of questions and some

[00:07:32.309]
patients we might have jumped a biopsy.

[00:07:35.028]
We've been able to do contrast and say,

[00:07:37.358]
OK, this finding is OK, we don't have

[00:07:39.389]
to, and we've we've saved the patient a procedure and

[00:07:41.389]
we know she's OK. We will see it. I know

[00:07:43.389]
after we roll this out, we'll be seeing

[00:07:45.709]
some cancers and.

[00:07:47.488]
Just going to

[00:07:49.069]
continuing a courses, um, I was

[00:07:51.088]
amazed at

[00:07:52.528]
seeing some of the cases they were able to find that

[00:07:55.170]
I, I never would have or it would have been

[00:07:57.329]
later on, uh, before we would have be able to

[00:07:59.369]
find them without contrast.

[00:08:00.928]
And you touched on this a little bit. Who qualifies for

[00:08:03.009]
this exactly?

[00:08:04.329]
So the main two

[00:08:06.369]
groups of patients they'll qualify are women with dense

[00:08:08.449]
breast tissue.

[00:08:09.569]
Um, and, and women with, with elevated

[00:08:11.869]
risk factors. Um, some, some patients

[00:08:14.069]
come in knowing that they have dense breasts

[00:08:16.199]
or knowing a lot of people will know that

[00:08:18.389]
they have high risk factors that may be from

[00:08:20.470]
from family history or so. Um,

[00:08:22.428]
but those are also things we're gonna screen for and we're

[00:08:24.470]
gonna ask always, we ask about family

[00:08:26.670]
history. Um, we have a lot of patients who

[00:08:28.720]
ask us about genetic testing and go for

[00:08:30.798]
that. Um, with dense breast, uh,

[00:08:33.158]
breast density is a thing that

[00:08:35.359]
I have to notify every woman by law

[00:08:37.359]
of do they have dense breasts or not.

[00:08:39.668]
So you're gonna get a letter from me and

[00:08:41.840]
about 40% of my patients,

[00:08:43.759]
40% of US women have dense breasts, and

[00:08:45.759]
so they'll get a letter telling us they have dense breasts,

[00:08:47.879]
and those are the main types that

[00:08:50.080]
patients that qualify for this. Does

[00:08:52.109]
insurance cover this?

[00:08:54.178]
So it's hard to speak with all the

[00:08:56.379]
health insurance plans out there.

[00:08:58.460]
Generally for diagnostic purposes,

[00:09:00.859]
um, it should, it should be covered,

[00:09:03.178]
um, but yeah, that's just really gonna be

[00:09:05.219]
plan specific for patients.

[00:09:07.219]
And what future developments do you see

[00:09:09.418]
for contrast enhanced mammography or breast imaging

[00:09:11.779]
more broadly?

[00:09:13.259]
What I'm most excited

[00:09:15.320]
for is, um,

[00:09:17.168]
in the, in the broad screening for

[00:09:19.210]
women with dense tissue. And, and that's

[00:09:21.450]
always been

[00:09:22.719]
a more challenging area of mammography. I

[00:09:24.769]
always tell my patients that I, I, I've

[00:09:26.928]
been in practice

[00:09:28.330]
11 years now, but

[00:09:30.298]
It was great that when I trained, I,

[00:09:32.500]
I got to see

[00:09:33.619]
so much of the evolution of breast imaging. I mean, we hung

[00:09:36.178]
films, uh, so old films

[00:09:38.259]
and, and reading a woman's mammogram with dense

[00:09:40.428]
breasts was very tough. And then I

[00:09:42.580]
saw the jump to very soon when I was

[00:09:44.619]
still in training in, uh, in residency to

[00:09:46.729]
digital mammograms.

[00:09:48.178]
And then right after I finished, we went to the 3D

[00:09:50.418]
mammograms

[00:09:51.779]
and those jumps were phenomenal.

[00:09:54.529]
Um,

[00:09:55.529]
still with dense tissue can be concerning to people

[00:09:57.889]
because I'll have some patients

[00:10:00.009]
say, well, I hear the mammogram is not

[00:10:02.048]
as good, and I'll say

[00:10:03.840]
10 years ago it wasn't, and now

[00:10:05.918]
they're really great, but we still offer

[00:10:08.048]
additional tests. Right now we do whole breast ultrasound.

[00:10:10.928]
What I've been looking for is,

[00:10:14.070]
you know, what's that good test that really helps

[00:10:16.210]
me out in patients with dental breast tissue

[00:10:18.279]
and also

[00:10:19.928]
on the flip side doesn't take.

[00:10:22.460]
As much time as say an MRI might

[00:10:24.700]
be, um, if, if they don't qualify

[00:10:26.899]
for MRI and and won't have

[00:10:29.408]
the rate of false positives where

[00:10:31.500]
you have to put people through procedures or more workups

[00:10:33.820]
when we're trying to help them and and screen

[00:10:35.899]
them and every new

[00:10:37.928]
technology, I'll tell people I'm a skeptic. I,

[00:10:41.029]
I'll usually it takes me a few years and

[00:10:42.940]
if you I don't go to a course and say, OK, I love

[00:10:45.058]
that, I want to implement that.

[00:10:46.658]
And there are certainly tons

[00:10:48.908]
of articles that I'll read in the literature

[00:10:51.269]
and I think, I don't know that I like that. And, and

[00:10:53.548]
this one I've read a lot about it over the

[00:10:55.668]
past few years and finally

[00:10:57.428]
went and did some training on it and thought,

[00:10:59.509]
this is what I've been looking for. This is that happy

[00:11:01.548]
medium for my patients with dense breasts.

[00:11:03.908]
And then also I have patients that

[00:11:06.580]
We get MRI screening of

[00:11:08.788]
that that can't do it. Some women have pacemakers,

[00:11:11.058]
some women are are claustrophobic and and

[00:11:13.259]
I don't wanna make them, you know, get in that that magnet

[00:11:15.580]
that's that's not just the easiest test

[00:11:17.580]
or they have other medical devices,

[00:11:19.739]
um,

[00:11:20.859]
or can't have the MRI contrast.

[00:11:23.700]
And this is gonna be a great tool for

[00:11:25.849]
some of those patients that can't have or or just

[00:11:28.038]
don't want to get MRI. It's

[00:11:30.048]
gonna really help them.

[00:11:31.649]
Well, Doctor Roton, thank you so much for talking

[00:11:33.678]
about the support and information.

[00:11:35.509]
What lasting message would you like to leave with our

[00:11:37.609]
audience about CEM

[00:11:40.889]
and um the, the

[00:11:43.019]
progress that you're seeing in the field?

[00:11:45.649]
The main thing, and it's my soapbox that I

[00:11:47.649]
always say is

[00:11:49.168]
mammograms every year. So I, I tell all my patients,

[00:11:51.609]
um, You know, the, the best

[00:11:53.808]
thing, uh, and the reason we're so

[00:11:56.038]
successful at treating breast cancer

[00:11:58.090]
is because, uh, I'll tell patients, I want

[00:12:00.129]
to find it when it's early and when it's small.

[00:12:02.609]
Um, I wish the mammogram just

[00:12:05.279]
zapped it and, and prevented it.

[00:12:07.168]
Um, and, and every woman is

[00:12:09.210]
going to be affected in some way by, by breast

[00:12:11.369]
cancer.

[00:12:12.479]
It not,

[00:12:13.798]
and not necessarily the thing personally, but it may be a friend

[00:12:15.969]
or family member. Everyone knows someone

[00:12:18.279]
and has someone close to them that's affected by breast cancer.

[00:12:21.009]
And the only way you can treat it is if I, if I find it

[00:12:23.200]
and, and find it early. So I

[00:12:25.469]
always say, every year,

[00:12:27.330]
um, and I try to be aware of that, right? Being a

[00:12:29.849]
guy that I haven to go through that, I just,

[00:12:31.928]
I'm a big cheerleader for it and encourage my patients

[00:12:34.529]
every single year,

[00:12:35.808]
beginning at age 40.

[00:12:37.369]
Um, and then

[00:12:39.009]
the technological advances are great.

[00:12:41.450]
They help our confidence, they help us

[00:12:43.649]
find things earlier and detect them

[00:12:45.769]
better. And

[00:12:47.330]
the thing I really love the most that that

[00:12:49.570]
impacts patients on a day to day basis is

[00:12:52.210]
we don't have to worry about things that that don't

[00:12:54.288]
need worrying about.

[00:12:55.649]
Well, thank you. Thanks for being here today. Yeah,

[00:12:57.889]
thank you for having me.

[00:12:59.090]
And that's it for this episode of AFMCTV.

[00:13:01.369]
Thanks for watching and have a great day.