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Ad Hoc with a Doc – Breast Radiology and Cryoablation

Hi, welcome to another episode of Ad Hoc
with a Doc. I’m Dr. Dan Rubin, and I’m here today with a longtime friend and
colleague Dr. Belinda Barclay-White we both practice in Scottsdale Arizona. Dr.
Barclay-White is a breast radiologist and has long time been somebody that we’ve worked with and advocated with and I’m so excited to be here to talk to you
about breast radiology, mammography, cryoablation of breast tumors, I know our
audience is going to love this episode. I wanted to thank you for being a friend to naturopathic medicine for all these years and all you’ve done for the
community of women in Scottsdale. It’s been wonderful people just say the
greatest things about your services so it’s been my privilege to work with you. Oh,
you’re making my head swell, thank you, thank you very much. I do want to ask, why
breast radiology ? Why so specific of an interest? So I, I was a
general radiologist in a group of men basically when I came to Phoenix and I
was so struck by how badly breast imaging was being done and as a woman I
really felt that we needed to improve on that. So I was encouraged by my
partners to go into breast imaging as the only female in the group and I
quickly became really sort of enthralled with it and I educated myself with all
the local conferences and all the national conferences and became very
passionate about it and then decided that practicing in the hospital setting,
there was only so much I could do to make it a more positive experience
having a mammogram so I actually opened Breastnet 20 years
ago. And Breastnet is the name of your practice? Yes. That’s Breastnet right
here in Scottsdale. Well interesting, mammography. I for myself have not
really been able to sort out the different articles and statistics you
know coming out about mammography but specifically the guidelines.
I’m confused which means that probably the public may be confused too
as to what the guidelines are can you talk a little bit about current
guidelines for mammography or detection? I certainly will. So there’s so much
confusion about guidelines, my patients are definitely confused they ask me
every year because it’s changing on a year-to-year basis. The referring
physicians are very confused some of them are actually telling women no you
don’t have to screen maybe every couple of years. Over age 65 they’re being told
they don’t have to screen anymore. The issue is that breast cancers in young
women are not good actors they tend to grow faster. Okay. And they they need to
be picked up earlier, so if we don’t start screening until 50, which was what
one recommendation we saw out there we missed that window of finding that
cancer and actually…Of finding it early…Of finding it early, and unfortunately, as
many women in their 40s are diagnosed with cancer as in their 50s. If you
stopped doing mammograms from 40 to 50, you are basically not finding those
cancers. When you say stop doing mammograms from 40 to 50, do you mean somebody gets
one at 40, it was clear, so now they say you don’t need one for another decade, or
do you mean that we’re just not going to screen people who are between 40 and 50
years old? I’ve actually seen that as a recommendation. And these recommendations
come mainly from a UPTS, the United States Preventive task force which is a
non-government body. Okay. That, that basically looks at data from all the
studies that are done on mammography. In the U.S.? In the U.S., and actually
they use it on the main it’s mainly U.S. and Canada.
So North American, but they’re not taking into account European guidelines or
studies. No. Okay, that’s an interesting point. No, and they, the one, actually most of the
studies have been done on screenings for instance from Sweden where they clearly
show a benefit. Of? Of screening mammogram, finding that cancer earlier.
And no one disputes that finding it earlier is better than finding
large and late. Certainly. That would make a difference for treatment as well. Absolutely,
absolutely. So you said younger, you know, maybe not
screening younger women as a guideline. What is considered a younger woman? So
they, in the past, we’ve screened from age 40. Forty. And and women with a higher risk,
we’ve screened them ten years before their mother or sister was diagnosed. Who determines the high-risk? Are those the general practitioners, the internal
medicine Doc’s out there? Yes, most of the time, the family history is going to be
something that the doctor is aware of and will say well then let’s get your
mammogram a little bit earlier than 40, right? Got it, and in clinical practice, in
real time, in the trenches, day to day, do you see differences in the population of
people coming to you for screening or has it not really changed despite the
changes in the guidelines? Actually, most women are still coming at age 40 and I
think that it’s been so discussed, that even though the recommendation may be
from their doctor you know well you could probably not do it or do it every
two years until you’re 50, between the age of 40 and 50, most of these women are
actually very well informed and that certainly the women that come to me tend
to start screening around age 40. And the American College of Surgery, Breast
Surgeons, the Gynecologists, all the all the doctors that actually see these
women are very much behind annual screening beginning at age 40 and even
younger if the high-risk. Got it. But there is a caveat there. Okay. Because young
women have dense breast tissue, younger and it’s easier for us to miss a small
cancer in that dense breast tissue. On mammography? On mammography. Okay. So
there’s there’s a sort of growing trend now towards screening with ultrasound in
dense breast tissue. So using both or once you determine that a per mammography
that it’s dense or per exam, then you only do ultrasound? We have to do an initial
mammogram. Okay. To see what the density is like because feeling in the breast doesn’t tell us
at all. Got it, okay. It’s what you see on the mammogram. So if they have dense breasts on the mammogram
then I we usually have the conversation about combining screening ultrasound
with mammography, or even instead of mammography for that first ten years.
Now that’s a big point. Now that, are you leading the way on this locally? Very much so. I have to
tell patients this isn’t a ‘standard of care’ but just from experience of when I
find and how I find breast cancers I’m actually offering that option in the
younger women screening with ultrasound then starting mammography at age forty
and even then maybe alternating mammography and ultrasound. So it’s not enough
for somebody to come in and say I have dense breasts, I just want to do an
ultrasound I’m afraid of the radiation from mammography. That’s not good enough
for you, doing an exam and taking their word for it. You have to determine
whether or not they’re dense breast tissue via mammography first. Right, and
if they’ve had a mammogram somewhere else and they know that’s great
information and then I will have the conversation with them and explain the
limitations of mammography the limitations of doing ultrasound only,
which are actually less for me in that young woman but you know we’ll explain
all of that to the patient, and then we come up with an educated decision on what
they’re comfortable with and what we’re comfortable with. Some people complain that mammograms are
uncomfortable, and I can absolutely assume that they are, or that they hurt
when they get them. What about ultrasound, is ultrasound
painful? No, ultrasound’s messy. Okay. Because we have to use gel, but no, it’s
not painful. There’s no compression with ultrasound. And um, just to be
certain, there are lesions that you found on ultrasound that you didn’t see and
mammography? Absolutely. In fact, on average of all the studies now that have
been sort of put together, we’re finding twice as many cancers on ultrasound in
dense breast tissue even compared with 3d. So either 2d or 3d mammography still
misses cancers half the time. Let’s say that stat again for our audience.
You’re finding how many more cancers? So we’re finding twice as many cancers in dense
breast tissue if we do ultrasound at the time of the mammogram. So Dr. Barclay-White, why aren’t more
centers doing ultrasound at the time of mammography? So it’s partly we’re doing
mammography because we’ve been doing it for a long time this inertia of changing
the medical thinking. Doesn’t happen quickly. It doesn’t happen quickly. Probably
one of the slowest moving vehicles in the United States to change. I mean
completely unlike IT. It’s the opposite to IT. Right, so that is an issue. Trying
to change this inertia. So we’ve already started talking about well, the
limitations of mammography, which I agree with. We can miss small non-calcified cancers. It’s an old, it’s an old technology, is it not? Right. This is still x-ray’s. It’s still an old
technology. So there are some newer technologies out there that find cancers
smaller and earlier, such as whole breast screening ultrasound and MRI of the
breast. There are some other technologies where we inject a radionuclide but I’m
sort of concerned about that because that’s a high dose of radiation. What’s that test called? That’s called scintimammograpy. And the purpose of that is to
have whatever that radio-nucleotide go to an area of breast cancer and then
you detect it with like a Geiger counter or something? Exactly. Okay. Exactly. So it’s a new use
for an older technology? Yes. Okay. Indeed. But then you’re injecting radiation into
the person. Yes. Okay. What happens when you find these smaller cancers? Is, does,
the patient automatically get referred to a surgeon? So, so this yes. Over the
years that is definitely what happened so I may diagnose the cancer with a
with a needle biopsy. I’m sorry, sorry to stop you, but you do the biopsy here as
needed? Yes, so if we find something on
mammogram or ultrasound that looks suspicious, we will do a needle biopsy
under ultrasound guidance or under guidance of a mammogram that’s
called a stereotactic. Right here the same day sometimes as they get there? I
try and do it the same day if they’re not on any blood thinners. Okay. Excellent service.
And then we get the results the following day. So, so if it’s if it’s a
low-grade, small cancer, more than likely they’re going to be
advised to have a lumpectomy. Okay. To remove that tumor. So I send the patient
with her, the path results to the breast surgeon and that’s traditionally
what happens. A low-grade, so it’s not very aggressive, meaning low-grade. Small tumor,
does that mean under a half a centimeter? Typically. Okay. Yes. What happens if that
small cancer is invasive? So most cancers that we will diagnose on mammogram as
particularly ultrasound are invasive tumors. Okay. Right? So invasive just
means all cancers start within the lining of the milk duct. Okay. So invasive
means that that cancer has gone through the wall of the milk duct. That’s an
invasive cancer. It broke through its capsule so to speak. Right. Okay. And they can still be
very small. Okay. And very low-grade, and slow growing, but they present that way. Okay. And then there are some other cancers that present with micro
calcifications that grow along the milk duct okay and don’t actually go through
the milk duct and that’s called ductal carcinoma in situ. Okay. Okay, and that’s a
pre-invasive situation and patients-. Is that considered a cancer? Yes it is, because
the trouble is that we know that 30% of them will become invasive and it’s
really difficult to know which 30%. And this is the DCIS that people talk about or
that’s the terminology so if anybody’s out there, DCIS is this pre is it
considered a pre cancer or a cancer? And where are we with that? It’s called a pre invasive. Pre invasive cancer. Yes. Some people do term it a pre cancer and we know that these
women do very well on the whole, so so we take away that 30% chance of it becoming
an invasive tumor right? By removing it. So most of those DCIS’s still
undergo lumpectomy. Okay. Um, for these smaller tumors, I know there’s a
procedure that you’ve brought to Arizona called cryoablation. Yes. Where does that
fit in in the continuum? Does that…I’m very interested to hear about it. I’m excited
about the work that you’ve been doing. You and
I have shared a couple patients, such an interesting technology. Is it considered
a surgical technique? So no, it’s done percutaneously through a little tiny
incision in the breast under ultrasound guidance. In an operating room or just in
the office here? Actually most people are doing it in an office setting. I’m doing
it here in my ultrasound room. Okay. So the exciting thing about it is that it
is an alternative to lumpectomy in certain cancers. We have to be very
selective about which ones we can treat that way. But a small, less than 1.5
centimeters which is about the size of a grape. Okay. Right? 1.5 centimeters, small,
low-grade, so there’s grade 1 2 & 3 if this is grade 1 or 2 we can do those
tumors with no DCIS, that ductal carcinoma in situ we were talking about. Okay. We don’t like DCIS, because DCIS can be there without us knowing about it. Okay. And that’s an increased risk for recurrence. Right? Is there a certain age
range of somebody who’s appropriate for this treatment? We to date have been
doing women over age 65, the the recent study that is is now coming out we’ve
rounded the age down to over age 50, which is very exciting for the same low
grade you know well acting tumors. So fifty years of age or older now. With a less than one point five centimeter tumor, low grade, without surrounding DCIS. Exactly. In the area. Yes. And is it a single treatment in the office or multiple
treatments? No, it’s a single treatment. We basically use liquid nitrogen. Okay. We introduce a probe through the middle of the little tiny cancer under
ultrasound guidance. Okay, just, you said percutaneous, yes, which means
through the skin. Through the skin, we introduce it’s a really like having a needle biopsy of
the breast. It’s no more invasive than that. And we leave the probe in there
depending on the size of the tumor we freeze for six minutes and then we
thaw for six minutes, and then when we freeze again for six
minutes thaw and take the catheter out and that’s it. That’s the treatment. And they walk out of here and they go to lunch and they go to the movies. They’re all so excited. So it’s amazing. People that are selected for this and are
appropriate can have their breast cancer treated non surgically, in the office, in
the middle of the day, and still go to lunch afterwards. Yes. What about pain? Is it painful? No, because the the cryo portion of it
actually freezes the nerve endings as it goes. So we use local anesthetic to
introduce the probe and position the probe through the center of the tumor
and then as we start to freeze the whole area is deadened anyway. So no, not
painful. Post pain, so pain you know an hour afterwards or whatever. I haven’t
haven’t had any patients complaining of any. Is it discomfort? They’re aware of it. They walk
out of here with a sort of an ice-ball right? Yeah, inside the breast. They can feel a cold breast that thaws within two hours, and then gradually over the next few days they’ll
be aware of a lump because that’s the dead tissue that we’ve frozen around the
cancer, and that lump shrinks slowly average two years and you can’t feel it. Two years. So besides the convenience and that it’s non-surgical and then it’s
percutaneous, one of the more exciting things that I understand about
cryoablation is that the immune system is involved in the response. And that’s
what I’m so excited about. So, so what happens when you’ve, we freeze these
tumors, is the actual cancer cell is still recognizable. It’s dead, but the cancer
cell, the structure of the cell is still recognizable by the immune system and
you probably understand this better than I do. Oh, this is wonderful. Yes. But that then, the body, because as soon as we’ve created that big mass of fat, vessels will come into the area, we create an inflammatory reaction and the
body does its job, which is to mop up the debris I’ve left there, the frozen debris,
right? Absolutely. Yes! And a part of that is that the immune cells involved in an inflammatory
response recognize those dead cancer cells and they start building up an immunity to them. So there’s some really promising
information coming out some in this country but also in Japan and China
where they’re doing a lot more of these about inciting that immune response and
there’ve been very well documented cases where patients have had multiple tumors,
they’ve frozen one, and the other tumors have disappeared. Now that’s wonderful,
because that’s a wonderful intersection between what you’re doing cryotherapy
cryoablation and naturopathic medicine. Because as naturopathic doctors, we’ve
spent great time researching and understanding and testing and working
with patients about about the functionality of their immune system. And
it’s a great intersection for us too, because the patients that I’ve had that
who have had their breast tumors cryoablated we’ve certainly worked on their
immune system whether we’re testing it and then stimulating it and and in
giving them the agents that they need to stimulate their immune system it’s it’s
like about time! That’s exactly how I feel we’ve been treating cancers you
know the size of a grape or smaller the same way we were treating cancers that
presented ulcerating through the breast skin for 50 years and now that I’m
finding them this small, I I was beginning to get very dejected that the treatment wasn’t changing. Yeah, well we have innate, biological responses that need to
be engaged. So we know that your first and last response to a tumor is your
immune system the problem is, is why did the tumor grow? Did it masquerade itself
so the immune system couldn’t see it? Was there something impairing the immune
system to begin with? Is there something genomic which impairs the immune system? We don’t necessarily know the answer to the question because the tumor is here
presenting to it, but cryotherapy can uncloak that tumor for the immune system. Yes. So as naturopathic doctors, if we can help the immune system be as strong
as it can be whether it be by diet, or lifestyle, mental-emotional issues,
removing a toxicant that is known to impair the immune system that the inside
the in the patient’s environment or by use of supplementation and combine it
with the cryotherapy that you’re doing in your office; I’m looking forward to a
very useful therapy with people with early stage cancers. Absolutely. And it’s
so much less daunting, you know a lot of patients won’t have a mammogram: A…
because they’re worrying about the radiation which is a very…they shouldn’t
be worrying about that. But a lot of patients don’t have a mammogram because
if I find a small tumor, they’re worried about the treatment. And if you can now offer something so much less formidable to them, I’m hoping that it will encourage
people to try and find their tumors earlier. But the cryoablation at this
point is really open to somebody who’s between uhh, who is over age 50. So for the younger, earlier detected, even if it’s a small, low-grade tumor, the standard of care still
surgical lumpectomy. It is still surgical lumpectomy and like all things this is
so new, in the breast. We’ve been using it in other places actually prostate. Which to me, seems much more formidable and invasive, than the breast,
but I guess that’s where I come from. But um, but…I’ve forgotten what I was going to say. That’s okay, you know I’m certainly hoping
that even though it’s been recently introduced that this is one that makes
so much physiological sense, helps with cost containment, reduces stress and
anxiety from the patient…that this is going to move along as quickly as it
really needs to, which sounds like it needs to move pretty quickly, be brought
to other age groups, making sure that it’s safe for people. And it’s exciting
that you’ve brought this here to our local Phoenix metropolitan area. Well
thank you Dan, and I’m so pleased that you are so supportive of it, and it just
fits with what you do. In fact, when I started doing it the first thing I did
was come round and tell you about it right? I remember our meeting, yeah. Yeah that’s right! Well thank you. Thank you for being part of the show today. I appreciate it, like I said,
appreciate all the support and the work that you’ve done for the community. It’s
a privilege to be your colleague and for Ad Hoc with a Doc, this is Dr. Dan
Rubin with Dr. Belinda Barclay-White of Breastnet. Thank you Dan,
can I say likewise, I think you’ve done a huge amount of support for the community
as well I think what you do is wonderful.

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