TEDWomen 2010
Deborah Rhodes: A test that finds 3x more breast tumors, and why it's not available to you
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Working with a team of physicists, Dr. Deborah Rhodes developed a new tool for tumor detection that's 3 times as effective as traditional mammograms for women with dense breast tissue. The life-saving implications are stunning. So why haven't we heard of it? Rhodes shares the story behind the tool's creation, and the web of politics and economics that keep it from mainstream use.
Deborah Rhodes - Physician, cancer researcher
Deborah Rhodes is an expert at managing breast-cancer risk. The director of the Mayo Clinic’s Executive Health Program is now testing a gamma camera that can see tumors that get missed by mammography. Full bio
Deborah Rhodes is an expert at managing breast-cancer risk. The director of the Mayo Clinic’s Executive Health Program is now testing a gamma camera that can see tumors that get missed by mammography. Full bio
Double-click the English transcript below to play the video.
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There are two groups of women
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when it comes to screening mammography --
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women in whom mammography works very well
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and has saved thousands of lives
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and women in whom it doesn't work well at all.
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Do you know which group you're in?
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If you don't, you're not alone.
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Because the breast has become
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are very political organ.
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The truth has become lost
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in all the rhetoric
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coming from the press, politicians,
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radiologists
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and medical imaging companies.
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I will do my best this morning
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to tell you what I think is the truth.
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But first, my disclosures.
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I am not a breast cancer survivor.
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I'm not a radiologist.
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I don't have any patents,
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and I've never received any money from a medical imaging company,
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and I am not seeking your vote.
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(Laughter)
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What I am
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is a doctor of internal medicine
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who became passionately interested in this topic
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about 10 years ago
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when a patient asked me a question.
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She came to see me
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after discovering a breast lump.
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Her sister had been diagnosed with breast cancer
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in her 40s.
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She and I were both very pregnant at that time,
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and my heart just ached for her,
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imagining how afraid she must be.
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Fortunately, her lump proved to be benign.
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But she asked me a question:
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how confident was I
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that I would find a tumor early on her mammogram
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if she developed one?
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So I studied her mammogram,
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and I reviewed the radiology literature,
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and I was shocked to discover
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that, in her case,
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our chances of finding a tumor early on the mammogram
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were less than the toss of a coin.
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You may recall a year ago
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when a firestorm erupted
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after the United States Preventive Services Task Force
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reviewed the world's mammography screening literature
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and issued a guideline
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recommending against screening mammograms
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in women in their 40s.
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Now everybody rushed to criticize the Task Force,
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even though most of them weren't in anyway familiar
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with the mammography studies.
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It took the Senate just 17 days
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to ban the use of the guidelines
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in determining insurance coverage.
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Radiologists were outraged
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by the guidelines.
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The pre-eminent mammographer in the United States
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issued the following quote
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to the Washington Post.
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The radiologists were, in turn, criticized
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for protecting their own financial self-interest.
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But in my view,
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the radiologists are heroes.
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There's a shortage of radiologists
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qualified to read mammograms,
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and that's because mammograms are one of the most complex
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of all radiology studies to interpret,
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and because radiologists
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are sued more often
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over missed breast cancer
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than any other cause.
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But that very fact is telling.
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Where there is this much legal smoke,
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there is likely to be some fire.
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The factor most responsible for that fire
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is breast density.
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Breast density refers to the relative amount of fat --
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pictured here in yellow --
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versus connective and epithelial tissues --
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pictured in pink.
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And that proportion
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is primarily genetically determined.
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Two-thirds of women in their 40s
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have dense breast tissue,
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which is why mammography doesn't work as well in them.
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And although breast density generally declines with age,
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up to a third of women
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retain dense breast tissue
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for years after menopause.
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So how do you know if your breasts are dense?
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Well, you need to read the details
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of your mammography report.
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Radiologists classify breast density
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into four categories
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based on the appearance of the tissue on a mammogram.
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If the breast is less than 25 percent dense,
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that's called fatty-replaced.
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The next category
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is scattered fibroglandular densities,
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followed by heterogeneously dense
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and extremely dense.
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And breasts that fall into these two categories
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are considered dense.
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The problem with breast density
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is that it's truly the wolf in sheep's clothing.
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Both tumors and dense breast tissue
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appear white on a mammogram,
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and the X-ray often can't distinguish between the two.
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So it's easy to see this tumor
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in the upper part of this fatty breast.
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But imagine how difficult it would be
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to find that tumor in this dense breast.
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That's why mammograms find
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over 80 percent of tumors in fatty breasts,
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but as few as 40 percent in extremely dense breasts.
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Now it's bad enough that breast density
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makes it hard to find a cancer,
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but it turns out
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that it's also a powerful predictor
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of your risk for breast cancer.
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It's a stronger risk factor
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than having a mother or a sister with breast cancer.
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At the time my patient posed this question to me,
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breast density was an obscure topic
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in the radiology literature,
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and very few women having mammograms,
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or the physicians ordering them,
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knew about this.
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But what else could I offer her?
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Mammograms have been around since the 1960's,
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and it's changed very little.
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There have been surprisingly few innovations,
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until digital mammography was approved
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in 2000.
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Digital mammography is still an X-ray of the breast,
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but the images
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can be stored and manipulated digitally,
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just like we can with a digital camera.
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The U.S. has invested
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four billion dollars
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converting to digital mammography equipment,
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and what have we gained from that investment?
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In a study funded by over 25 million taxpayer dollars,
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digital mammography was found
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to be no better over all
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than traditional mammography,
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and in fact, it was worse in older women.
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But it was better in one group,
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and that was women under 50
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who were pre-menopausal and had dense breasts,
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and in those women,
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digital mammography found twice as many cancers,
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but it still only found 60 percent.
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So digital mammography
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has been a giant leap forward
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for manufacturers
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of digital mammography equipment,
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but it's been a very small step forward for
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womankind.
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What about ultrasound?
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Ultrasound generates more biopsies
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that are unnecessary relative to other technologies,
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so it's not widely used.
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And MRI is exquisitely sensitive for finding tumors,
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but it's also very expensive.
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If we think about disruptive technology,
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we see an almost ubiquitous pattern
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of the technology getting smaller and less expensive.
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Think about iPods compared to stereos.
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But it's the exact opposite in health care.
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The machines get ever bigger
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and ever more expensive.
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Screening the average young woman with an MRI
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is kind of like driving to the grocery store in a Hummer.
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It's just way too much equipment.
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One MRI scan
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costs 10 times what a digital mammogram costs.
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And sooner or later, we're going to have to accept the fact
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that health care innovation
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can't always come at a much higher price.
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Malcolm Gladwell wrote an article in the New Yorker
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on innovation,
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and he made the case that scientific discoveries
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are rarely the product of one individual's genius.
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Rather, big ideas can be orchestrated,
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if you can simply gather
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people with different perspectives in a room
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and get them to talk about things
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that they don't ordinarily talk about.
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It's like the essence of TED.
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He quotes one innovator who says,
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"The only time a physician and a physicist get together
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is when the physicist gets sick."
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(Laughter)
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This makes no sense,
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because physicians have all kinds of problems
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that they don't realize have solutions.
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And physicists have all kinds of solutions for things
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that they don't realize are problems.
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Now, take a look at this cartoon
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that accompanied Gladwell's article,
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and tell me if you see something disturbing
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about this depiction of innovative thinkers.
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(Laughter)
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So if you will allow me a little creative license,
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I will tell you the story
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of the serendipitous collision
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of my patient's problem
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with a physicist's solution.
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09:00
Shortly after her visit,
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I was introduced to a nuclear physicist
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at Mayo
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named Michael O'Conner,
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who was a specialist in cardiac imaging,
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something I had nothing to do with.
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And he happened to tell me
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about a conference he'd just returned from in Israel,
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where they were talking about a new type of gamma detector.
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Now gamma imaging has been around for a long time
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to image the heart,
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and it had even been tried to image the breast.
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But the problem was
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that the gamma detectors
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were these huge, bulky tubes,
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and they were filled with these scintillating crystals,
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and you just couldn't get them close enough around the breast
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to find small tumors.
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But the potential advantage was
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that gamma rays, unlike X-rays,
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are not influenced by breast density.
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But this technology
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could not find tumors when they're small,
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and finding a small tumor is critical for survival.
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If you can find a tumor
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when it's less than a centimeter,
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survival exceeds 90 percent,
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but drops off rapidly
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as tumor size increases.
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But Michael told me about
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a new type of gamma detector that he'd seen,
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and this is it.
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It's made
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not of a bulky tube,
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but of a thin layer of a semiconductor material
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that serves as the gamma detector.
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And I started talking to him
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about this problem with breast density,
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and we realized that we might be able to get this detector
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close enough around the breast
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to actually find small tumors.
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So after putting together
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a grid of these cubes with tape --
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(Laughter)
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-- Michael hacked off the X-ray plate
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of a mammography machine
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that was about to be thrown out,
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and we attached the new detector,
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and we decided to call this machine
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Molecular Breast Imaging, or MBI.
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This is an image from our first patient.
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And you can see, using the old gamma technology,
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that it just looked like noise.
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But using our new detector,
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we could begin to see the outline of a tumor.
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So here we were, a nuclear physicist,
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an internist,
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soon joined by Carrie Hruska, a biomedical engineer,
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and two radiologists,
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and we were trying to take on
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the entrenched world of mammography
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with a machine that was held together by duct tape.
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To say that we faced
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high doses of skepticism
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in those early years
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is just a huge understatement,
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but we were so convinced that we might be able to make this work
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that we chipped away with incremental modifications
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to this system.
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This is our current detector.
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And you can see that it looks a lot different.
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The duct tape is gone,
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and we added a second detector on top of the breast,
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which has further improved our tumor detection.
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So how does this work?
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The patient receives an injection of a radio tracer
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that's taken up by rapidly proliferating tumor cells,
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but not by normal cells,
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and this is the key difference from mammography.
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Mammography relies on differences
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in the appearance of the tumor from the background tissue,
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and we've seen that those differences
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can be obscured in a dense breast.
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But MBI exploits
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the different molecular behavior of tumors,
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and therefore, it's impervious to breast density.
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After the injection,
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the patient's breast is placed between the detectors.
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And if you've ever had a mammogram --
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if you're old enough to have had a mammogram --
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you know what comes next:
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pain.
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You may be surprised to know
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that mammography is the only radiologic study
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that's regulated by federal law,
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and the law requires
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that the equivalent of a 40-pound car battery
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come down on your breast during this study.
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But with MBI,
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we use just light, pain-free compression.
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12:57
(Applause)
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And the detector
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then transmits the image to the computer.
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So here's an example.
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You can see, on the right, a mammogram
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showing a faint tumor,
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the edges of which are blurred by the dense tissue.
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But the MBI image shows that tumor much more clearly,
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as well as a second tumor,
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which profoundly influence that patient's surgical options.
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In this example, although the mammogram found one tumor,
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we were able to demonstrate three discrete tumors --
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one is small as three millimeters.
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Our big break came in 2004.
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After we had demonstrated that we could find small tumors,
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we used these images
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to submit a grant to the Susan G. Komen Foundation.
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And we were elated when they took a chance
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on a team of completely unknown investigators
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and funded us to study
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1,000 women with dense breasts,
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comparing a screening mammogram to an MBI.
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Of the tumors that we found,
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mammography found
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only 25 percent of those tumors.
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MBI found 83 percent.
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Here's an example from that screening study.
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The digital mammogram was read as normal
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and shows lots of dense tissue,
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but the MBI shows an area of intense uptake,
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which correlated with a two-centimeter tumor.
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In this case, a one-centimeter tumor.
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And in this case,
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a 45-year-old medical secretary at Mayo,
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who had lost her mother to breast cancer when she was very young,
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wanted to enroll in our study.
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And her mammogram showed an area of very dense tissue,
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but her MBI showed an area
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of worrisome uptake,
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which we can also see on a color image.
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And this corresponded
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to a tumor the size of a golf ball.
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But fortunately it was removed
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before it had spread to her lymph nodes.
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So now that we knew that this technology
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could find three times more tumors in a dense breast,
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we had to solve one very important problem.
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We had to figure out how to lower the radiation dose,
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and we have spent the last three years
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making modifications to every aspect of the imaging system
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to allow this.
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And I'm very happy to report that we're now using a dose of radiation
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that is equivalent to the effective dose
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from one digital mammogram.
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And at this low dose, we're continuing this screening study,
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and this image from three weeks ago
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in a 67-year-old woman
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shows a normal digital mammogram,
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but an MBI image
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showing an uptake that proved to be a large cancer.
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So this is not just young women that it's benefiting.
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It's also older women with dense tissue.
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And we're now routinely using one-fifth the radiation dose
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that's used in any other type of gamma technology.
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MBI generates four images per breast.
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MRI generates over a thousand.
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It takes a radiologist
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years of specialty training
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to become expert in differentiating
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the normal anatomic detail
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from the worrisome finding.
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But I suspect even the non-radiologists in the room
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can find the tumor on the MBI image.
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But this is why MBI
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is so potentially disruptive --
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it's as accurate as MRI,
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it's far less complex to interpret,
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and it's a fraction of the cost.
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But you can understand why there may be
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forces in the breast-imaging world
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who prefer the status quo.
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After achieving what we felt were remarkable results,
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our manuscript was rejected
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by four journals.
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After the fourth rejection,
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we requested reconsideration of the manuscript,
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because we strongly suspected
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that one of the reviewers who had rejected it
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had a financial conflict of interest
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in a competing technology.
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Our manuscript was then accepted
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and will be published later this month
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in the journal Radiology.
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(Applause)
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We still need to complete the screening study using the low dose,
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and then our findings will need to be replicated
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at other institutions,
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and this could take five or more years.
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If this technology is widely adopted,
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I will not benefit financially in any way,
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and that is very important to me,
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because it allows me to continue to tell you the truth.
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But I recognize --
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(Applause)
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I recognize that the adoption of this technology
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will depend as much on economic
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and political forces
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as it will on the soundness of the science.
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The MBI unit has now been FDA approved,
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but it's not yet widely available.
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So until something is available
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for women with dense breasts,
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there are things that you should know
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to protect yourself.
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17:58
First, know your density.
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Ninety percent of women don't,
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and 95 percent of women don't know
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that it increases your breast cancer risk.
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18:07
The State of Connecticut became the first and only state
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to mandate that women receive notification
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of their breast density
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after a mammogram.
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18:17
I was at a conference of 60,000 people in breast-imaging
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last week in Chicago,
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and I was stunned that there was a heated debate
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as to whether we should be telling women
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what their breast density is.
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Of course we should.
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And if you don't know, please ask your doctor
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or read the details of your mammography report.
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Second, if you're pre-menopausal,
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try to schedule your mammogram
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in the first two weeks of your menstrual cycle,
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when breast density is relatively lower.
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Third, if you notice a persistent change in your breast,
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insist on additional imaging.
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And fourth and most important,
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the mammography debate will rage on,
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but I do believe that all women 40 and older
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should have an annual mammogram.
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Mammography isn't perfect,
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but it's the only test that's been proven
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to reduce mortality from breast cancer.
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But this mortality banner
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is the very sword
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which mammography's most ardent advocates use
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to deter innovation.
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19:18
Some women who develop breast cancer
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die from it many years later,
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and most women, thankfully, survive.
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So it takes 10 or more years
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for any screening method
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to demonstrate a reduction
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in mortality from breast cancer.
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19:33
Mammography's the only one that's been around long enough
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to have a chance of making that claim.
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It is time for us to accept
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both the extraordinary successes of mammography
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and the limitations.
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We need to individualize screening
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based on density.
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For women without dense breasts,
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mammography is the best choice.
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But for women with dense breasts;
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we shouldn't abandon screening altogether,
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we need to offer them something better.
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The babies that we were carrying
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when my patient first asked me this question
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are now both in middle school,
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and the answer has been so slow to come.
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She's given me her blessing
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to share this story with you.
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After undergoing biopsies
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that further increased her risk for cancer
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and losing her sister to cancer,
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she made the difficult decision
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to have a prophylactic mastectomy.
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We can and must do better,
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not just in time for her granddaughters
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and my daughters,
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but in time for you.
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Thank you.
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(Applause)
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ABOUT THE SPEAKER
Deborah Rhodes - Physician, cancer researcherDeborah Rhodes is an expert at managing breast-cancer risk. The director of the Mayo Clinic’s Executive Health Program is now testing a gamma camera that can see tumors that get missed by mammography.
Why you should listen
For all of the lives it saves, mammography still cannot detect the early onset of breast cancer in as many as one of every four women ages 40 to 49. And women with dense breast tissue are four to six times more likely to develop cancer than others. Deborah Rhodes and her colleagues at the Mayo Clinic in Minnesota think they’ve found an effective way to screen these high-risk patients: molecular imaging.
Rhodes, who specializes in evaluating and managing breast cancer, is collaborating with a nuclear physicist and various radiologists on a dual-head “gamma camera” that can capture the tiny tumors in dense tissue. The new technique, which would complement (not replace) mammography, is sensitive enough to pick up a mass two-fifths of an inch in diameter. Molecular breast imaging requires patients to be injected with a radioactive drug, but it is much more comfortable than the vise-grip mammogram and is expected to cost only slightly more.
Deborah Rhodes | Speaker | TED.com