There are two groups of women when it comes to screening mammography -- women in whom mammography works very well and has saved thousands of lives and women in whom it doesn't work well at all. Do you know which group you're in? If you don't, you're not alone. Because the breast has become a very political organ. The truth has become lost in all the rhetoric coming from the press, politicians, radiologists and medical imaging companies. I will do my best this morning to tell you what I think is the truth. But first, my disclosures. I am not a breast cancer survivor. I'm not a radiologist. I don't have any patents, and I've never received any money from a medical imaging company, and I am not seeking your vote.
Postoje dve grupe žena kada je mamografija u pitanju: žene kod kojih mamografija odlično funkcioniše i spasila je hiljade života i žene kod kojih uopšte ne funkcioniše dobro. Da li znate kojoj grupi pripadate? Ako ne znate, niste usamljene. Zato što su grudi postale u velikoj meri politizovan organ. Istina se izgubila u svoj toj retorici novinara, političara radiologa i medicinskih kompanija. Daću sve od sebe ovog jutra da vam kažem ono što smatram da je istina. Ali najpre, moje stanovište. Ja nisam preživela rak. Nisam radiolog. Nemam nikakav patent, i nisam nikada primila novac od medicinske kompanije. I ne tražim vaš glas.
(Laughter)
(Smeh)
What I am is a doctor of internal medicine who became passionately interested in this topic about 10 years ago when a patient asked me a question. She came to see me after discovering a breast lump. Her sister had been diagnosed with breast cancer in her 40s. She and I were both very pregnant at that time, and my heart just ached for her, imagining how afraid she must be. Fortunately, her lump proved to be benign. But she asked me a question: how confident was I that I would find a tumor early on her mammogram if she developed one? So I studied her mammogram, and I reviewed the radiology literature, and I was shocked to discover that, in her case, our chances of finding a tumor early on the mammogram were less than the toss of a coin.
Ja sam doktorka interne medicine koja je postala veoma zainteresovana za ovu temu pre oko 10 godina kada mi je pacijentkinja postavila pitanje. Došla je kod mene nakon što je otkrila čvorić na dojci. Njenoj sestri je već bio dijagnostikovan rak dojke u njenim četrdesetim. I ona i ja smo bile u odmakloj trudnoći u to vreme, i srce me je bolelo zbog nje, kad sam zamislila koliko je uplašena. Na svu sreću, ispostavilo se da je njen čvorić bio benigan. Ali mi je postavila pitanje: koliko sam sigurna da ću pronaći tumor u ranoj fazi na mamografu ako ga ima? Tako da sam prostudirala njen mamograf, i radiološku literaturu, i bila sam šokirana kada sam otkrila da, u njenom slučaju, šanse za pronalaženje ranog tumora na mamografu su bile manje nego da bacamo novčić.
You may recall a year ago when a firestorm erupted after the United States Preventive Services Task Force reviewed the world's mammography screening literature and issued a guideline recommending against screening mammograms in women in their 40s. Now everybody rushed to criticize the Task Force, even though most of them weren't in anyway familiar with the mammography studies. It took the Senate just 17 days to ban the use of the guidelines in determining insurance coverage. Radiologists were outraged by the guidelines. The pre-eminent mammographer in the United States issued the following quote to the Washington Post. The radiologists were, in turn, criticized for protecting their own financial self-interest. But in my view, the radiologists are heroes. There's a shortage of radiologists qualified to read mammograms, and that's because mammograms are one of the most complex of all radiology studies to interpret, and because radiologists are sued more often over missed breast cancer than any other cause. But that very fact is telling.
Možda se sećate pre nekoliko godina kada se digla buka kada je Radna grupa za prevenciju Sjedninjenih Država revidovala svetsku literaturu o skeniranju mamografom i izdala smernice koje preporučuju da se mamografija ne radi ženama u četrdesetim. Svi su požurili da kritikuju Radnu grupu, iako većina njih nije ni na koji način bila upoznata sa studijama o mamografiji. Senatu je trebalo samo 17 dana da zabrani upotrebu ovih smernica kao odrednica za određivanje obima osiguranja. Radiolozi su bili besni zbog smernica. Istaknuti stručnjak za mamografiju u SAD je dao sledeću izjavu "Vašington Postu". Sa druge strane, radiolozi su bili kritikovani jer su štitili sopstvene finansijske interese. Ali po mom mišljenju, radiolozi su heroji. Postoji manjak radiologa kvalifikovanih za čitanje mamograma i to je zbog toga što su mamogrami jedni od najkompleksnijih radioloških studija za interpretaciju, i zato što radiolozi su tuženi češće zbog raka dojke koji su prevideli nego iz bilo kog drugog razloga. Ali sama ta činjenica nam nešto govori.
Where there is this much legal smoke, there is likely to be some fire. The factor most responsible for that fire is breast density. Breast density refers to the relative amount of fat -- pictured here in yellow -- versus connective and epithelial tissues -- pictured in pink. And that proportion is primarily genetically determined. Two-thirds of women in their 40s have dense breast tissue, which is why mammography doesn't work as well in them. And although breast density generally declines with age, up to a third of women retain dense breast tissue for years after menopause.
Tamo gde ima mnogo 'pravničkog' dima, verovatno ima i vatre. Faktor koji je najveći uzročnik te vatre je gustina tkiva dojke. Gustina tkiva se odnosi na odnos količine masnog tkiva... ovde prikazane žutom bojom... prema vezivnom i epitelnom tkivu... koje je prikazano roze bojom. I taj odnos je uglavnom određen genetikom. Dve trećine žena u četrdesetim godinama ima gusto tkivo dojke i zbog toga mamografija kod njih ne funkcioniše tako dobro. Iako gustina tkiva dojke uglavnom opada sa starošću, i do trećina žena zadržava gusto tkivo dojke godinama nakon menopauze.
So how do you know if your breasts are dense? Well, you need to read the details of your mammography report. Radiologists classify breast density into four categories based on the appearance of the tissue on a mammogram. If the breast is less than 25 percent dense, that's called fatty-replaced. The next category is scattered fibroglandular densities, followed by heterogeneously dense and extremely dense. And breasts that fall into these two categories are considered dense. The problem with breast density is that it's truly the wolf in sheep's clothing. Both tumors and dense breast tissue appear white on a mammogram, and the X-ray often can't distinguish between the two. So it's easy to see this tumor in the upper part of this fatty breast. But imagine how difficult it would be to find that tumor in this dense breast. That's why mammograms find over 80 percent of tumors in fatty breasts, but as few as 40 percent in extremely dense breasts.
Prema tome, kako znate da su vaše grudi 'guste'? Pa, treba da čitate detalje vašeg mamografskog izveštaja. Radiolozi klasifikuju gustinu tkiva dojke na četiri kategorije prema izgledu tkiva na mamogramu. Ako dojka ima gustinu manju od 25 procenata smatra se da je ispunjena masnim tkivom. Sledeća kategorija ima raštrkane fibroglandularne mase, praćena heterogeno gustom i ekstremno gustom. I grudi koje spadaju u ove dve kategorije se smatraju gustim. Problem sa gustinom dojki je što je to vuk u ovčijoj koži. I tumori i gusto tkivo dojke izgledaju belo na mamogramu i rendgen često ne može da napravi razliku između ta dva. Tako da je lako uočiti tumor na gornjem delu ove dojke sa masnim tkivom. Ali zamislite kako bi bilo teško naći tumor u ovoj dojci sa gustim tkivom. Zato mamografi pronalaze preko 80 procenata tumora u dojkama sa masnim tkivom, ali manje od 40 procenata u dojkama sa veoma gustim tkivom.
Now it's bad enough that breast density makes it hard to find a cancer, but it turns out that it's also a powerful predictor of your risk for breast cancer. It's a stronger risk factor than having a mother or a sister with breast cancer. At the time my patient posed this question to me, breast density was an obscure topic in the radiology literature, and very few women having mammograms, or the physicians ordering them, knew about this. But what else could I offer her?
Sad, dovoljno je loše to što gustina tkiva dojke otežava pronalaženje raka, ali ispostavilo se da je takođe i veoma jak faktor rizika za dobijanje raka dojke. To je veći faktor rizika nego imati majku ili sestru sa rakom dojke. U vreme kada mi je pacijentkinja postavila ovo pitanje, gustina tkiva dojke je bila nepoznata tema u radiološkoj literaturi i veoma malo žena koje su išle na mamografiju, i lekara koji su ih vodili, su znali za ovo. Ali šta sam joj drugo mogla ponuditi?
Mammograms have been around since the 1960's, and it's changed very little. There have been surprisingly few innovations, until digital mammography was approved in 2000. Digital mammography is still an X-ray of the breast, but the images can be stored and manipulated digitally, just like we can with a digital camera. The U.S. has invested four billion dollars converting to digital mammography equipment, and what have we gained from that investment? In a study funded by over 25 million taxpayer dollars, digital mammography was found to be no better over all than traditional mammography, and in fact, it was worse in older women. But it was better in one group, and that was women under 50 who were pre-menopausal and had dense breasts, and in those women, digital mammography found twice as many cancers, but it still only found 60 percent. So digital mammography has been a giant leap forward for manufacturers of digital mammography equipment, but it's been a very small step forward for womankind.
Mamografi su tu od 1960-ih. I veoma malo se promenilo. Bilo je iznenađujuće malo inovacija, dok digitalna mamografija nije bila odobrena u 2000. Digitalna mamografija je i dalje rendgensko snimanje dojke, ali slike mogu biti čuvane i obrađivane digitalno, kao što bi se to radilo na digitalnom foto-aparatu. SAD su investirale četiri milijarde dolara u prelazak na digitalnu mamografiju. I šta smo dobili od te investicije? U studiji koju je finansiralo 25 miliona dolara od poreza, zaključeno je da digitalna mamografija u celini uzev nije bolja od tradicionalne mamografije. I zapravo je lošija kod starijih žena. Ali bila je bolja kod jedne grupe a to su žene mlađe od 50 godina koje još nisu ušle u menopauzu i imaju gusto tkivo dojke. I kod tih žena digitalna mamografija je pronašla duplo više tumora ali je i dalje pronašla samo 60 procenata. Tako da je digitalna mamografija bila veliki korak napred za proizvođače opreme za digitalnu mamografiju, ali je bila veoma mali korak napred za žene.
What about ultrasound? Ultrasound generates more biopsies that are unnecessary relative to other technologies, so it's not widely used. And MRI is exquisitely sensitive for finding tumors, but it's also very expensive. If we think about disruptive technology, we see an almost ubiquitous pattern of the technology getting smaller and less expensive. Think about iPods compared to stereos. But it's the exact opposite in health care. The machines get ever bigger and ever more expensive. Screening the average young woman with an MRI is kind of like driving to the grocery store in a Hummer. It's just way too much equipment. One MRI scan costs 10 times what a digital mammogram costs. And sooner or later, we're going to have to accept the fact that health care innovation can't always come at a much higher price.
A šta je sa ultrazvukom? Ultrazvuk generiše više biopsija koje su nepotrebne u odnosu na druge tehnologije, tako da nema široku upotrebu. Magnetna rezonanca je izuzetno precizna za pronalaženje tumora, ali je takođe veoma skupa. Ako pomislimo na tehnologiju imamo skoro opšti princip da se tehnologija smanjuje i postaje jeftinija. Pogledajte iPod u poređenju sa muzičkim stubom. Ali u zdravstvu je proces obrnut. Mašine se stalno povećavaju i postaju skuplje. Skenirati prosečnu mladu ženu magnetnom rezonancom je u neku ruku kao voziti se Hamerom u samoposlugu. To je jednostavno suviše opreme. Jedno skeniranje magnetnom rezonancom košta 10 puta više nego digitalni mamograf. I pre ili kasnije, moraćemo da prihvatimo činjenicu da inovacija u zdravstvu ne može uvek doći po mnogo višoj ceni.
Malcolm Gladwell wrote an article in the New Yorker on innovation, and he made the case that scientific discoveries are rarely the product of one individual's genius. Rather, big ideas can be orchestrated, if you can simply gather people with different perspectives in a room and get them to talk about things that they don't ordinarily talk about. It's like the essence of TED. He quotes one innovator who says, "The only time a physician and a physicist get together is when the physicist gets sick." (Laughter) This makes no sense, because physicians have all kinds of problems that they don't realize have solutions. And physicists have all kinds of solutions for things that they don't realize are problems. Now, take a look at this cartoon that accompanied Gladwell's article, and tell me if you see something disturbing about this depiction of innovative thinkers.
Malkolm Gledvel je napisao članak u ''Njujorkeru'' na temu inovacije, i njegovo stanovište je da su naučna otkrića retko proizvod individualnog genija. Nasuprot tome, velike ideje mogu biti orkestrirane, ako jednostavno skupite ljude sa različitim pogledima u jednu prostoriju i navedete ih da razgovaraju o stvarima o kojima obično ne razgovaraju. To je kao suština TED-a. On citira jednog pronalazača koji kaže: ''Jedini put kada se lekar i fizičar sretnu je kada se fizičar razboli.'' (Smeh) Ovo nema nikakvog smisla, jer lekari imaju raznorazne probleme za koje ni ne znaju da postoje rešenja. A fizičari imaju razna rešenja za stvari za koje ne shvataju da su problemi. Sad, pogledajte ovu ilustraciju koja je pratila Gledvelov članak, i recite mi da li vidite nešto uznemirujuće u opisu inovativnih mislilaca.
(Laughter)
(Smeh)
So if you will allow me a little creative license, I will tell you the story of the serendipitous collision of my patient's problem with a physicist's solution. Shortly after her visit, I was introduced to a nuclear physicist at Mayo named Michael O'Conner, who was a specialist in cardiac imaging, something I had nothing to do with. And he happened to tell me about a conference he'd just returned from in Israel, where they were talking about a new type of gamma detector. Now gamma imaging has been around for a long time to image the heart, and it had even been tried to image the breast. But the problem was that the gamma detectors were these huge, bulky tubes, and they were filled with these scintillating crystals, and you just couldn't get them close enough around the breast to find small tumors. But the potential advantage was that gamma rays, unlike X-rays, are not influenced by breast density. But this technology could not find tumors when they're small, and finding a small tumor is critical for survival. If you can find a tumor when it's less than a centimeter, survival exceeds 90 percent, but drops off rapidly as tumor size increases. But Michael told me about a new type of gamma detector that he'd seen, and this is it. It's made not of a bulky tube, but of a thin layer of a semiconductor material that serves as the gamma detector. And I started talking to him about this problem with breast density, and we realized that we might be able to get this detector close enough around the breast to actually find small tumors.
Tako da ako mi date malo kreativnog prostora, ispričaću vam priču o sudbinskom susretu problema moje pacijentkinje i rešenja fizičara. Ubrzo nakon njene posete, upoznala sam nuklearnog fizičara na Majo klinici po imenu Majkl O'Koner, koji je bio specijalista za kardiološko snimanje, nešto što sa mnom nije imalo nikakve veze. I on mi je slučajno ispričao o konferenciji u Izraelu sa koje se upravo vratio, gde su pričali o novom tipu gama detektora. Sad, gama snimanje se koristi već dugo za snimanje srca, i čak je bilo isprobano za snimanje dojki. Ali problem je bio u tome što su gama detektori ogromne, glomazne cevi i ispunjene su ovim svetlucavim kristalima, i niste ih jednostavno mogli dovoljno približiti dojci da bi pronašli male tumore. Ali potencijalna prednost je bila u tome da na gama zrake, za razliku od rendgenskih, ne utiče gustina tkiva. Ali ova tehnoogija nije mogla naći male tumore. A nalaženje malih tumora je krucijalno za preživljavanje. Ako možete pronaći tumor kada je manji od centimetra, verovatnoća da se preživi je preko 90 procenata ali ona strmo opada kako se veličina tumora povećava. Ali Majkl mi je ispričao o novom tipu gama detektora koji je video i to je to. Napravljen je ne od glomazne cevi već od tankog sloja poluprovodljivog materijala koji funkcioniše kao gama detektor. I počela sam da razgovaram sa njim o problemu gustine tkiva dojke, i shvatili smo da bi ovaj detektor mogli dovoljno približiti grudima da bi zaista našli male tumore.
So after putting together a grid of these cubes with tape -- (Laughter) -- Michael hacked off the X-ray plate of a mammography machine that was about to be thrown out, and we attached the new detector, and we decided to call this machine Molecular Breast Imaging, or MBI. This is an image from our first patient. And you can see, using the old gamma technology, that it just looked like noise. But using our new detector, we could begin to see the outline of a tumor.
Nakon što smo napravili raster od ovih kocki povezanih lepljivom trakom - (Smeh) - Majkl je skinuo rendgensku ploču sa mamografa koji je bio škartiran. I pričvrstili smo novi detektor, i odlučili smo da nazovemo ovu mašinu Molekularni skener dojke, odnosno MSD. Ovo je snimak naše prve pacijentkinje. Kao što možete videti, koristeći staru gama tehnologiju, izgleda kao šum. Ali koristeći naš novi detektor, mogli smo videti obrise tumora.
So here we were, a nuclear physicist, an internist, soon joined by Carrie Hruska, a biomedical engineer, and two radiologists, and we were trying to take on the entrenched world of mammography with a machine that was held together by duct tape. To say that we faced high doses of skepticism in those early years is just a huge understatement, but we were so convinced that we might be able to make this work that we chipped away with incremental modifications to this system. This is our current detector. And you can see that it looks a lot different. The duct tape is gone, and we added a second detector on top of the breast, which has further improved our tumor detection.
Tako da eto nas, nukleani fizičar, internista kojima se uskoro pridružila Keri Hraška, biomedicinski inženjer, i dvoje radiologa, i pokušavali smo da se suprotstavimo krutom svetu mamografije sa mašinom koja je bila sastavljena lepljivom trakom. Reći da smo se suočili sa velikom količinom skepticizma u tim ranim godinama je blago rečeno. Ali bili smo tako ubeđeni da možemo da učinimo da ovo finkcioniše da smo nastavljali dalje sa postepenim modifikacijama sistema. Ovo je naš trenutni detektor. I možete videti da izgleda dosta drugačije. Nema više lepljive trake, i dodali smo drugi detektor na gornji deo dojke, koji je dodatno poboljšao detekciju tumora.
So how does this work? The patient receives an injection of a radio tracer that's taken up by rapidly proliferating tumor cells, but not by normal cells, and this is the key difference from mammography. Mammography relies on differences in the appearance of the tumor from the background tissue, and we've seen that those differences can be obscured in a dense breast. But MBI exploits the different molecular behavior of tumors, and therefore, it's impervious to breast density. After the injection, the patient's breast is placed between the detectors. And if you've ever had a mammogram -- if you're old enough to have had a mammogram -- you know what comes next: pain. You may be surprised to know that mammography is the only radiologic study that's regulated by federal law, and the law requires that the equivalent of a 40-pound car battery come down on your breast during this study. But with MBI, we use just light, pain-free compression. (Applause) And the detector then transmits the image to the computer.
Kako ovo zapravo funkcioniše? Pacijent dobije injekciju radioaktivnog materijala koji obeležava i koji upijaju ćelije tumora koje se brzo dele a ne upijaju ga normalne ćelije. I ovo je osnovna razlika u odnosu na mamografiju. Mamografija se oslanja na razlike u izgledu između tumora i okolnog tkiva, i videli smo da ove razlike mogu biti zanemarljive kod dojki sa gustim tkivom. Ali MSD koristi drugačije molekularno ponašanje tumora, i zbog toga je imun na problem gustine tkiva dojke. Posle injekcije, grudi pacijenta se postave između detektora. I ako ste ikada radili mamogram - ako ste dovoljno stari da ste radili mamogram - znate šta sledi: bol. Možda ćete biti iznenađeni da je mamografija jedina radiloška studija koja je regulisana federalnim zakonom, i zakon zahteva da se uređaj ekvivalentan akumulatoru od oko 18kg spusti na vašu dojku prilikom ovog pregleda. Ali kod MSD mi koristimo lak, bezbolni pritisak. (Aplauz) I detektor onda prenosi sliku na računar.
So here's an example. You can see, on the right, a mammogram showing a faint tumor, the edges of which are blurred by the dense tissue. But the MBI image shows that tumor much more clearly, as well as a second tumor, which profoundly influence that patient's surgical options. In this example, although the mammogram found one tumor, we were able to demonstrate three discrete tumors -- one is small as three millimeters.
Prema tome, evo primera. Možete videti na desnoj strani mamogram koji pokazuje bledi tumor, čije su ivice zamućene gustim tkivom dojke. Ali MSD pokazuje ovaj tumor mnogo jasnije, kao i još jedan tumor, što suštinski utiče na pacijentove mogućnosti za operaciju. U ovom primeru, iako je mamograf našao jedan tumor, mi smo mogli da pokažemo tri mala tumora... jedan je veličine 3 milimetra.
Our big break came in 2004. After we had demonstrated that we could find small tumors, we used these images to submit a grant to the Susan G. Komen Foundation. And we were elated when they took a chance on a team of completely unknown investigators and funded us to study 1,000 women with dense breasts, comparing a screening mammogram to an MBI. Of the tumors that we found, mammography found only 25 percent of those tumors. MBI found 83 percent. Here's an example from that screening study. The digital mammogram was read as normal and shows lots of dense tissue, but the MBI shows an area of intense uptake, which correlated with a two-centimeter tumor. In this case, a one-centimeter tumor. And in this case, a 45-year-old medical secretary at Mayo, who had lost her mother to breast cancer when she was very young, wanted to enroll in our study. And her mammogram showed an area of very dense tissue, but her MBI showed an area of worrisome uptake, which we can also see on a color image. And this corresponded to a tumor the size of a golf ball. But fortunately it was removed before it had spread to her lymph nodes.
Naš veliki proboj je došao u 2004. Nakon što smo pokazali da možemo pronaći male tumore, iskoristili smo ove snimke da se prijavimo za finansiranje Suzan G. Komen fondacije. I bili smo oduševljeni kada su dali šansu timu potpuno nepoznatih istraživača i finansirali nas da proučimo 1.000 žena sa gustim tkivom dojke, poredeći mamografsko snimanje sa našim MSD. Od tumora koje smo pronašli, mamograf je pronašao samo 25 procenata. MSD je pronašao 83 procenata. Evo primera iz te studije. Digitalni mamogram je bio crven kao i obično i pokazuje dosta gustog tkiva, ali MSD pokazuje prostor intenzivne boje, koji odgovara tumoru od dva centimetra. U ovom slučaju, tumor od jednog centimetra. A u ovom slučaju, četrdesetpetogodišnja medicinska sekretarica u Maju, koja je izgubila majku zbog raka dojke kad je bila veoma mala, je želela da bude deo naše studije. I njen mamogram je pokazivao predeo sa veoma gustim tkivom, ali je njen MSD pokazao deo sa zabinjavajućim intenzitetom koji vidimo i na snimku u boji. I ovo je odgovaralo tumoru velikom kao loptica za golf. Ali, na svu sreću, bio je odstranjen pre nego što se proširio na njene limfne čvorove.
So now that we knew that this technology could find three times more tumors in a dense breast, we had to solve one very important problem. We had to figure out how to lower the radiation dose, and we have spent the last three years making modifications to every aspect of the imaging system to allow this. And I'm very happy to report that we're now using a dose of radiation that is equivalent to the effective dose from one digital mammogram. And at this low dose, we're continuing this screening study, and this image from three weeks ago in a 67-year-old woman shows a normal digital mammogram, but an MBI image showing an uptake that proved to be a large cancer. So this is not just young women that it's benefiting. It's also older women with dense tissue. And we're now routinely using one-fifth the radiation dose that's used in any other type of gamma technology.
I sad kad smo znali da ova tehnologija može pronaći tri puta više tumora kod dojki sa gustim tkivom, morali smo da rešimo veoma bitan problem. Trebalo je da smislimo kako da smanjimo dozu radijacije. I proveli smo poslednje tri godine menjajući svaki aspekt sistema za snimanje da bi ovo omogućili. I srećna sam što mogu da vam saopštim da sad koristimo dozu radijacije koja je ekvivalentna efektivnoj dozi jednog digitalnog mamografa. I pri ovoj maloj dozi smo nastavili studiju i ovaj snimak od pre tri nedelje kod šezdesetsedmogodišnje žene pokazuje normalni digitalni mamogram, ali MSD snimak pokazuje mrlju koja se pokazala kao veliki tumor. Tako da nemaju samo mlade žene koristi od ovoga. Imaju i starije žene sa gustim tkivom dojke. I sada rutiski koristimo jednu petinu doze radijacije koja se koristi u bilo kom drugom tipu gama tehnologije.
MBI generates four images per breast. MRI generates over a thousand. It takes a radiologist years of specialty training to become expert in differentiating the normal anatomic detail from the worrisome finding. But I suspect even the non-radiologists in the room can find the tumor on the MBI image. But this is why MBI is so potentially disruptive -- it's as accurate as MRI, it's far less complex to interpret, and it's a fraction of the cost. But you can understand why there may be forces in the breast-imaging world who prefer the status quo.
MSD pravi po četiri slike za svaku dojku. Magnetna rezonanca preko hiljadu. Radiologu su potrebne godine specijalističke obuke da bi postao stručnjak u razlikovanju detalja normalne anatomije od zabrinjavajućih nalaza. Ali slutim da bi i oni u prostoriji koji nisu radiolozi mogli naći tumor na MSD snimku. Ali to je razlog zašto je MSD takva potencijalna pretnja. On je precizan kao i magnetna rezonanca, mnogo manje složen za tumačenje, i za mnogo manju cenu. Ali razumete zašto možda postoje sile u svetu skeniranja dojki kojima više odgovara status kvo.
After achieving what we felt were remarkable results, our manuscript was rejected by four journals. After the fourth rejection, we requested reconsideration of the manuscript, because we strongly suspected that one of the reviewers who had rejected it had a financial conflict of interest in a competing technology. Our manuscript was then accepted and will be published later this month in the journal Radiology. (Applause) We still need to complete the screening study using the low dose, and then our findings will need to be replicated at other institutions, and this could take five or more years. If this technology is widely adopted, I will not benefit financially in any way, and that is very important to me, because it allows me to continue to tell you the truth. But I recognize -- (Applause) I recognize that the adoption of this technology will depend as much on economic and political forces as it will on the soundness of the science.
Nakon što smo postigli nešto za šta smo smatrali da su izuzetni rezultati naš rad je bio odbijen od strane četiri časopisa. Posle četvrtog odbijanja, tražili smo da se ponovo razmotri naš rad, jer smo imali izražene sumnje da je jedan od ocenjivača koji ga je odbio imao finansijski konflikt interesa sa konkurentnom tehnologijom. Naš rad je onda bio prihvaćen i biće objavljen kasnije ovog meseca u časopisu "Radiologija". (Aplauz) Još treba da završimo studiju koristeći manju dozu i onda naši rezultati treba da budu ponovljeni u drugim institucijama. I to može potrajati pet ili više godina. Ako ova tehnologija bude široko usvojena, ja neću finansijski profitirati ni na koji način. I to mi je veoma važno jer mogu da nastavim da vam govorim istinu. Ali shvatam - (Aplauz) Shvatam da će primena ove tehnologije zavisiti koliko od ekonomskih i političkih struja toliko i od utemeljenosti nauke.
The MBI unit has now been FDA approved, but it's not yet widely available. So until something is available for women with dense breasts, there are things that you should know to protect yourself. First, know your density. Ninety percent of women don't, and 95 percent of women don't know that it increases your breast cancer risk. The State of Connecticut became the first and only state to mandate that women receive notification of their breast density after a mammogram. I was at a conference of 60,000 people in breast-imaging last week in Chicago, and I was stunned that there was a heated debate as to whether we should be telling women what their breast density is. Of course we should. And if you don't know, please ask your doctor or read the details of your mammography report. Second, if you're pre-menopausal, try to schedule your mammogram in the first two weeks of your menstrual cycle, when breast density is relatively lower. Third, if you notice a persistent change in your breast, insist on additional imaging. And fourth and most important, the mammography debate will rage on, but I do believe that all women 40 and older should have an annual mammogram.
MSD je do sada bio odobren od strane administracije za hranu i lekove, ali još uvek nije široko dostupan. Tako da dok nešto ne bude bilo na raspolaganju ženama sa gustim tkivom dojke ima stvari koje treba da znate da bi se zaštitile. Prvo, saznajte koliko vam je tkivo gusto. 90 procenata žena to ne zna, i 95 procenata žena ne zna da im to povećava rizik da dobiju rak. Država Konektikat je postala prva i jedina država koja propisuje da žene budu obaveštene o gustini svog tkiva dojke posle mamograma. Bila sam na konferenciji sa 60.000 ljudi koji se bave skeniranjem grudi prošle nedelje u Čikagu. I bila sam šokirana kada se razvila žustra rasprava o tome da li treba da govorimo ženama koja je gustina njihovog tkiva dojke. Naravno da bi trebalo. I ako ne znate, molim vas, pitajte svog lekara ili pročitaje detalje svog izveštaja sa mamografije. Drugo, ako niste još u menopauzi, probajte da zakažete sebi mamogram u prve dve nedelje menstrualnog ciklusa, kada je gustina tkiva dojke relativno manja. Treće, ako primetite trajnu promenu na svojoj dojci insistirajte na dodatnom snimanju. I četvrto i najvažnije, debata o mamografiji će i dalje divljati, ali ja i zaista verujem da bi sve žene od 40 i više godina trebalo da imaju mamogram jednom godišnje.
Mammography isn't perfect, but it's the only test that's been proven to reduce mortality from breast cancer. But this mortality banner is the very sword which mammography's most ardent advocates use to deter innovation. Some women who develop breast cancer die from it many years later, and most women, thankfully, survive. So it takes 10 or more years for any screening method to demonstrate a reduction in mortality from breast cancer. Mammography's the only one that's been around long enough to have a chance of making that claim. It is time for us to accept both the extraordinary successes of mammography and the limitations. We need to individualize screening based on density. For women without dense breasts, mammography is the best choice. But for women with dense breasts; we shouldn't abandon screening altogether, we need to offer them something better.
Mamografija nije savršena, ali je jedini test za koji je dokazano da smanjuje smrtnost od raka dojke. Ali ovaj barjak smrtnosti je oružje koje koriste najzagriženiji zagovornici mamografije da spreče inovaciju. Neke žene kod kojih se razvije rak dojke umru od njega posle mnogo godina. A većina žena, na svu sreću, preživi. Tako da treba 10 i više godina da bilo koji metod snimanja pokaže smanjenje u smrtnosti od raka dojke. Mamografija je jedina koja već dovoljno dugo postoji da bi mogla da to tvrdi. Vreme je da prihvatimo i izuzetne uspehe mamografije i njena ograničenja. Moramo da prilagodimo snimanje gustini. Za žene koje nemaju gusto tkivo grudi, mamografija je najbolji izbor. Ali za žene koje imaju gusto tkivo, ne smemo potpuno odustati od snimanja, moramo im ponuditi nešto bolje.
The babies that we were carrying when my patient first asked me this question are now both in middle school, and the answer has been so slow to come. She's given me her blessing to share this story with you. After undergoing biopsies that further increased her risk for cancer and losing her sister to cancer, she made the difficult decision to have a prophylactic mastectomy. We can and must do better, not just in time for her granddaughters and my daughters, but in time for you.
Bebe koje smo čekale kada mi je pacijentkinja postavila ovo pitanje sada obe završavaju osnovnu školu, i odgovor je došao tako polako. Dala mi je svoj blagoslov da sa vama podelim ovu priču. Nakon biopsija koje su dodatno povećale njen rizik da oboli od raka i nakon gubitka sestre zbog raka donela je tešku odluku da se podvrgne odstranjivanju dojke. Mi možemo i moramo da učinimo nešto bolje, ne samo na vreme za njene unuke, i moje ćerke, već na vreme za vas.
Thank you.
Hvala vam.
(Applause)
(Aplauz)