At the Forefront Live: Breast Cancer Screening - Annual vs. Personalized

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Hello and welcome to At the Forefront Live. There has been a longstanding debate in the medical community about when and how often women should be screened for breast cancer. Now, there is a major study to decide what are the best and safest guidelines for breast cancer screening. It's called the WISDOM Study. WISDOM stands for Women Informed to Screen Depending On Measures of risk. Now the study will assess whether personalized screening is as safe and effective compared to annual screening. 

Today, we have some of the preeminent experts in the field joining us on the program to discuss this important study. We want to remind everybody we'll take your questions live during the program, so start typing in the comments section. We'll try to get to as many as possible today. We also want to remind our viewers that this program is not designed to take the place of an actual visit with your physician. 

Joining us today, we have Dr. Funmi Olopade of University of Chicago Medicine, Dr. Laura Esserman of University of California, San Francisco, and Dr. Len Lichtenfeld of the American Cancer Society. You're here to talk about the WISDOM Study. It's a fascinating study and it's really interesting. And first of all, thank you because a couple of you traveled quite a distance to be here today. We appreciate that. 

Well, thank you for having us. 

So let's jump right. We'll talk about this study. And Dr. Esserman, I want to start with you. And could you just explain to us what the WISDOM Study is and why is it so necessary? 

Well, why don't I start with your second question first. And at the time that we started breast cancer screening, we thought that breast cancer was one disease and we thought everyone had the same risk for developing breast cancer. But over the last couple of decades, we've learned of course, that that is no longer true. We know that breast cancer really is many diseases. 

Just like every medical condition, you have something that ranges from very little risk to high risk. Like if it's an allergic reaction, you can have a hive or you can have anaphylactic shock. In breast cancer, we have small, slow-growing, indolent, idle cancers all the way to extremely aggressive cancers-- so that spectrum. So first of all, everyone isn't at risk for the same type of cancer. And we've learned now that people have varying amounts of risk. 

And so we need a modern-era study to really help us understand who's at risk for what kind of cancer and how can we tailor screening and prevention in a way that women get the best answers. And this is a study about women for women to help us generate the kind of information that we need to give people the best recommendations. 

And we're testing the one-size-fits-all approach, which is annual screening starting at age 40 through 75, and testing it against a more personalized screening program where we use all of the information that we know of today and continue to learn, which is about your inherited risk-- the genes that you inherit-- your mammographic density, a lot of the risk factors that we've learned about. And we put that together into a model and use that to assign people a risk and say, OK, using this, we're going to use that to determine when to start, when to stop, how often to screen, and with what modality. 

And we want to find out, as you said, if that's as safe, if there's less side effects and less false callbacks, if women prefer it, and whether we can actually promote prevention in that way. And that's the way we're going to generate the evidence to move into this next era of medicine and to set up a platform where we can continuously learn and women can participate in something to improve their own health. Both by participating, they'll get these better answers. And as we learn, we'll continue to improve. 

And it's a big study as well. 

It's a big study. 100,000 women is our goal. 

And why is that so critical that you have the big study? 

Well, so you can imagine there's these different kinds of breast cancer, even though breast cancer is one of the most common cancers that women get. Lung and breast cancer are the most common cancers. Still it's not very common, so really the average is like 4 per 1,000 in a mammogram. So we need enough cancers, and we need enough different types of cancers, and we need to make sure that we get the entire diverse population that is the United States. 

Caucasian woman, African-American women, Asian women, Latino women-- everyone has to participate, so we have enough to know and how to tailor our screening recommendations to each of these groups. And that's one of the opportunities that Funmi can talk about with the genetics. We know that the genetics are different for each of these groups, so we can continue to tailor screening. So we really need diverse and broad representation of the community and enough numbers that we can be confident in our recommendations to change and improve. 

Dr. Olopade, I'm curious when you look at a study-- particularly a study of this magnitude-- what kind of an impact will this have on the community, do you believe? 

Thank you for asking that question because you know Chicago is the heartland. We really have a very diverse population. And people live in their, neighborhoods but they know where they are from, right? And because we take care of diverse patients, we can't have one size fits all for our patients. So for decades in Chicago, we've been studying who is at risk for what cancer. And what we learned in Chicago is that young women get breast cancer-- young African-American women, young Latino women. 

And what we have found is that when you go out and you say, wait till you are 40 or wait till you're 50 to get your first mammogram, sometimes a lot of people come to my clinic and say, you know what? I'm 35. Why did I get breast cancer? So this study is going to benefit our community because we have a young urban population. And it's going to benefit women on the south side of Chicago, where my friend Laura Esserman was born, by the way. 

And that's why to celebrate the legacy of Reverend Martin Luther King, we thought Laura should bring WISDOM Study to Illinois and especially to Chicago because what we want is an inclusive study that says we're all in this together. We're looking for wisdom of women in the Midwest-- black women, white women, brown women, all women. We want to really activate the energy that is in the women's movement right now to take control of our health and to actually get the studies that we want done, so we can know what to do about screening and early detection of breast cancer. 

Genetics is what I specialize in. And we spent billions of dollars getting that first genome sequenced. And one of the things we said about the Genome Project is it's going to benefit all of us, right? And so this is one of the benefits of the Genome Project. We can now really do this test. It's going to be much, much cheaper than we ever imagined because the technology just keeps getting better. And what I want for our community is that all of us understand and can participate in the benefit of all the research that's been going on for decades right here at the University of Chicago. 

And I think, actually, one of the things that you don't want to do with these big screening studies is-- which is sort of what's happened-- we did these big studies in the '80s and early '90s, and we're still arguing about the same data. You know, we started these studies before we even knew there was an estrogen receptor or anything about breast cancer. And what we don't want to do is have a study that you roll out, and then takes you 10 years to do, 10 years to get adoption, and it's out of date. 

So we really want women to participate in a new movement, a new way of taking the best of science and finding out how it applies to them. We'll learn, and test, and keep changing and improving it. And everyone can be part of it. That's actually what I think is so exciting. This is something that Funmi and I have been talking about for a long time. 

I'm going to weigh it in here because I'm not only listening to the two wonderful people talk about so much in the passion of your heart, in which I fully understand. But I'm going to share with you was actually the studies went back to the 1960s. And I'm sorry to tell you-- age being what it is-- in practice, we started doing mammography back in the mid-1970s-- 

With the HIP study, yeah. 

--when it started to take off. And we have been using that same data and having the same arguments for decades. And now, here we are in a moment of time when as Dr. Olopade said, we have really learned so much more about the genome. And the genome is not just a point fixed in time. It's really a map of a journey. And we have to learn how to take that information and apply it. And actually one of the fascinating things that I've learned from the WISDOM trial was the fact that you could take some of these high-risk genomic markers-- genetic markers-- and actually study them even further to find out who within those particular groups may be at higher risk. 

That's right. 

So you know it's sort of like the phrase you keep doing the same thing over and over again, and why do you expect a different result? So it's time to start thinking innovatively, not that there's anything wrong with what we've done before. And it's still certainly American Cancer Society's perspective it's still important to remember that mammography is critically important as part of a screening process. However, we can't stay fixed in time. We have to be open to new ideas. We have to take that information. We have to look at populations. And again, Dr. Olopade mentioned and Dr. Esserman mentioned, looking at all women to understand what is going to be the best course forward for each of them and trying to tailor our efforts so much more than we've been able to, to this point in time. 

Well, Dr. Len, you just answered my next question, but I'm going to ask it anyway. So the American Cancer Society obviously on board with this, and it's important, and you're very interested in it. 

Yes, we are. And we've been fortunate to be part of it right from the very beginning from Dr. Esserman being a force of nature, shall we say, who had an idea and took it forward, and I think deserves a tremendous amount of credit for the work that she's done and the leadership she's provided. But I come back to the point I made a moment ago-- you can't stay still in science. We doctors-- it takes us a long time to change anything. I mean, somebody once said it was 17 years from a new discovery to actually making it work, unless there's a big financial piece, but we won't get into that discussion. 

Yes, I firmly believe on a very personal level that we need to entertain new ideas. It doesn't mean we abandon what we have so far because we still are accumulating evidence. And evidence is key to understanding how to best move forward. 

There's a new thing in medicine that started taking hold, and certainly the folks here at University of Chicago know it as well as anyone else. Sometimes less is more. And being able to tailor the needs to the person at hand is critically important in health care. We're all beginning to recognize that. And when you think about mammography, when you think about breast cancer screening, when you think about all of the things that can happen to a woman who gets a mammogram, it's important to understand and make sure that we're giving her the best advice and the best opportunities possible. 

Fantastic. Now, I do want to encourage people to go ahead and type your questions in. We're already getting quite a few questions from viewers. So we'll get to as many of those as possible. And I want to just throw out a couple of those if that's all right and we can get to those. The first question is, is this open to women of all ages? 

So this study actually is starting with women 40 to 75 because that's the ages at which we are recommending screening now. As Funmi was talking about earlier is that one of the things that we may learn from this is that there are certain groups of people where we should start earlier. And if it turns out that the incorporation of the genetic background on every patient is important, that's something you can do at age 25 and when you go to implement it. But for now, we're starting this study for women 40 to 75. 

Yeah. What I actually really love about the WISDOM Study is that it's targeting women from the ages of 40 to 75. But what I really would hope will be a secondary effect of this study is that everyone starts talking about what's my risk for breast cancer? When should I start screening? And if we all begin to have that conversation with our doctors and if women who participate in the study talk to other women, then we have a whole movement of women asking the question, what's my risk and when should I begin screening? 

And what should I do about it? And there's more than just screening that you can do about it. One of the things that we want to know is if you are at higher risk, there are things that you can do to lower that risk, and it depends on what there-- but we've spent hundreds of millions of dollars on prevention research, and we apply very little of it. 

Just like you know everyone knows about risk for heart disease, the Framingham study, think about the WISDOM Study as starting out as the Framingham study or just the beginning of applying that and trying to get it into common practice, where that's something that you would do. What's my risk for breast cancer? What should I be doing about it? How can I tailor it? What kind of cancer am I at risk for? All of that-- this is what this study is going to lead us to. 

I'm going to come back to a comment that Dr. Olopade made, which I think is actually personally incredibly important. And it's not always about the fancy science that we need to know about, it's the fundamental things we need to know about ourselves. So I write a blog periodically, but started back in the mid 1970s when my first blogs was about the importance of family history. And here I am still writing about the importance of family history. 

Yes, we have blood tests or we have other forms of testing that we can do to look at our risk, but before we get there, we should all know what our family history is. And we should have doctors, and other health professionals, clinicians who understand the importance of that. I can't tell you the number of times I've talked to people who have been treated at major centers who have not even had their family history examined. So there's a place to start and we can all do that easily. 

Yeah. And the reason why we really love having Dr. Len on this panel is that you know can get your risk from your father's side. Because every time we're talking about breast cancer, women only think, oh, I can only think about whether my mother had breast cancer. You need to know about your mother and father. 

Fantastic point. 

Right. And one of the reasons why we incorporated the spit test with Color is because in fact, some people also don't know their family history because they're adopted or they come from small families. And easier even than asking-- I mean, you should know your family history because that could add additional information and help us learn even more. 

But if we can pretty easily today-- you know, we have a partnership with Color Genomics who is helping us with the study. If in fact for the price of a mammogram, you can get all of that genetic information, my goodness, why don't we have it? And why don't we find the people at highest risk for breast cancer and do something about them? And maybe over the course of the study, we'll learn that the people with the lowest risk don't need as much screening or screening at all, like we do with colon cancer. 

Now, we have again, several questions coming in. One of the questions is where can I learn more about this study to see if I'm eligible? And I think we do have a graphic we can put at the bottom of the screen. Its wisdomstudy.org I believe is the website. 

That's correct. 

There we go. Pop that up, and just go there, and you can learn about the study and even sign up, I believe. Is that correct? 

Yes. 

Yes, you can just go in and sign up. 

That's fantastic. Another question from a viewer-- is the study restricted only to Chicago? I know the answer to that because we have people not from Chicago here, but go ahead and kind of tell how that works. 

So we started this study in California. At the first, we started with a partnership with the University of California Medical Centers. And we soon realized that we needed to really make it available to people across the state. And then the Sanford Health in the Midwest joined us and they have made their network of hospitals eligible. 

And then we have this fantastic opportunity to partner to spread this across the country with Blue Cross Blue Shield Association. Originally, Blue Cross Blue Shield of California helped sponsor this study under coverage with Evidence. This is actually a really important part of the study. 

And I actually really applaud Blue Cross Blue Shield for stepping up and saying, look, everyone has a responsibility to generate the information that will help women know how to get the best care. And I think all insurance companies should step up because this, in fact, is a very cost effective way because it helps us apply our resources in a smart way. 

And so they actually are covering-- all Blue Cross Blue Shield members are covered to participate in the WISDOM study. And the genetic testing, which is a part of it, is covered. And the way we do this is covered. And we have additional partnerships where we're working on getting broader aspects. And we hope that shortly, all of the insurance companies will step up and follow Blue Cross Blue Shield's lead. 

Yeah. And one of the things that's really exciting about this moment in time is that we have a National Cancer Institute that's been really focused on what we call the cancer moonshot. We're really talking about we have some things that if we implement it right now, we can cut cancer death rates just by doing what we know we're capable of doing. 

And so having a study of 100,000 women is an opportunity for us to partner with insurance companies, to partner with institutions like ours because we have a new program-- a specialized program of research excellence in breast cancer. And one of the things we are focused on is trying to reduce cancer health disparities. Why is it that we have such a huge gap between those of us who work in academic centers and those who practice in community centers in terms of when our studies actually get to the community? 

Now with our transnational research enterprise, with the NCI funding us and saying get the studies out of there, make sure clinical trials are accessible in the communities, we hope that more insurance companies will come to the table, that more community hospitals will come to the table, and that we can answer these questions together. 

You know it's interesting. I want to follow up on what you just said. It's a question I was going to ask you later in the show, but I think it's appropriate here. Why is there such a discrepancy or difference in screening for women of color, immigrant women, and different socioeconomic status women? Why is there such a difference and what can we do to solve that because obviously, it makes a huge difference? 

Absolutely. So one of the things that is happening in medicine is that we're actually looking at health systems. So we want to do personalized screening and we want every woman to have the opportunity to say, what is my risk for cancer? Well, imagine if a woman actually wants to do that, but the health system doesn't allow her to do that. Where does she go? 

So one of the things we've found in going to the communities on the south side of Chicago was that there was actually no access to mammography. People wouldn't know. Even if they wanted it, they couldn't get one. And so part of what we really want to do with this movement is to not only say a woman should know about their risk, but that we transform the health care system so that health systems will begin to manage the health of their population. 

They'll be able to remove any barrier to a woman getting the care that she needs. If a woman needs a lot more care because they have a high risk, then figure out how to get them there. And if they don't need as much risk, then figure out how to support each woman in the community in which they live. And that's why 100,000 women is actually not enough, but we have to start somewhere. 

Tim, let me expand that just a little bit because I think there is an important point that has to be made. The American Cancer Society just released "Cancer Statistics, 2019." And one of the key findings in that was not only the issue about the differences between black and white Americans or Hispanic Americans, but also about rural America and those cancers. 

And what was interesting about that study was in those cancers where we can screen and institute early detection techniques, there were big gaps based on where you live. And that could be related to socioeconomic. It could be related to education. It certainly is related to access because we have to make sure that every person-- and in this case, every woman-- has access to the best medical care possible, no matter where they live in the country because these differences are not inconsequential. 

Well, and these differences, it is a matter of life and death. 

Well, you know I think that you had asked before, why doesn't everyone just agree? Why isn't it so simple? Why not just screen everybody all the time? You know, I think this is the classic question. And it turns out I think it's important, especially when you have communities that don't have enough resources, you want to be smarter about how you use your resources. 

And I think it's important to know that screening has there's good sides of screening and there's downsides to screening. And you know sometimes when we call people back, we do a lot of biopsies, a lot of these biopsies turn out to be nothing. But until you get that answer, you think, oh, my gosh, I'm dying of breast cancer. Or if I find a cancer that turns out to be not that aggressive, and I give people a very aggressive treatment, then I might have done more harm than good. 

So really the opportunity for us to start figuring out who needs what and how we can apply our resources so the most people get the most good-- that's what we want. And that it is we talk about access. If we know which populations to focus on, we can really make that a criteria. And if we know for whom early prevention-- really figuring out how to turn the processes along or the people with the very highest risk to do preventive interventions-- that would do the most good for everyone. 

But so it all has to be integrated and we have to roll this out in a way that we can learn and keep learning. And women should demand this. They should demand the iPhone 15 of screening, not be on the old Motorola brick phone-- the handheld phone-- which is sort of where we are now. And we can't make the data from 30 and 40 years ago better. We just can't do it. It's not better, but we can start today. And every woman can share their wisdom. Everyone can participate and make it better. 

Can I make another point too going back something. 

Sure. Then I want to get to some more viewers questions. Go right ahead. 

Real quickly. The comment was made earlier about the insurance companies participating. Insurers spend tremendous amounts of money on treatments because they exist. And they have to be part of the solution going forward to help determine whether or not those treatments are valid. We have spent decades in some diseases offering treatments that we now know, literally 30 years later, were not as effective as we thought. 

Right. And so whose responsibility is it to get those answers? It's all of ours. Women should participate. We should be open to new ideas. And the insurance companies should be providing the platform to help us do the best we can and to keep learning. That's everyone's responsibility to change and make the future better. 

Sounds good. A couple more questions from our viewers. We're getting quite a few actually that are coming in. This one-- and this is kind of a Chicago-based question, but I think it's something that can be answered-- what do I have to do once I'm in this study? And this question was do I have to come to the University of Chicago? 

No. No, you don't. 

How does it work. 

Actually you sign up online. You just watch the video. So there's two things. The first thing that we ask you is if you're willing to participate, we explain about the study. And in fact, we have you can be randomized between the annual screening and the personalized screening. That's an important way in which we learn. But if you're not comfortable with that and you feel strongly that you want to choose one or the other, go ahead and do that and you can be in our observational arm. And you can participate that way as well. 

Once you're in an arm, you'll get a screening assignment. If you're in the personalized arm, you'll get a little spit kit that comes to your house, and you spit in it, and you send it back. It takes a month or two to get all the data together. And we get your mammogram, we'll get your density, put all that information together. And then if you signed up on your phone, you can do it on your phone. You can go to a computer in a library, in a kiosk at the University of Chicago, or at Ingalls Memorial Hospital, or wherever you happen to be. If you're traveling somewhere, you can do it on your phone. 

So really, it's just a matter of participating. You go get your mammograms where you would normally get them. And we send you questionnaires like every year. And if we think that you're at very high risk for your age group, we're going to call you, and we're going to reach out to you, and we're going to offer you options for reducing your risk-- talking about lifestyle, talking about options for prevention, places nearby where you live to go. So think of this as concierge for breast health medicine. 

You make it pretty easy. 

Very easy, very easy. 

I'm just going to step in here for just a minute-- 

All on the Salesforce platform. 

--and I'm going to ask Laura once again to give the website. 

Yes, wisdomstudy.org. 

There we go. 

Wisdomstudy.org. It's easy. 

And we will have that again-- there it is right there on the screen. We'll have it again at the end of the show too. So just if you need to write it down, it's pretty easy-- wisdomstudy.org. But we'll have it up there again at the end of the program. Another question from a viewer. I think this one is very interesting. Do you anticipate that in the future, every woman will receive genetic testing? How would that be implemented and which genes would you test for? 

That's a very good question. So the work that we're doing today is going to transform how we deliver care tomorrow. And so this is why these studies are really critical and very important. 20 years ago, we didn't even know what to do if you had a BRCA1 mutation. Today, we know what to do because some very brave women came forward. They got involved in research. And now, we know how to screen to detect cancer early in women with BRCA1 mutation and how to prevent it because we have studied it for more than two decades. 

So the question is not everyone has a BRCA1 or BRCA2 mutation, so what are all the other genes that come together to increase a woman's risk? What are the lifestyle choices that women make or lifestyle issues that make a woman more at risk for breast cancer? 

Now, we actually have the ability to collect the data, mine the data, and then use the data to now personalize risk, so that I'm not going in there telling every woman go get your mammogram. I tell them more than that. I tell them what their risk score is. And this is why we're talking about the polygenic risk score because the data are being collected, and now we want to test it in the population. How well does it work? How do we need to refine it? And once we refine it, how can we then refine what we tell every woman to do? 

So yes, in the future, you will have ability to personalize risk for everyone. And for us geneticists, we're thinking should everybody have their gene done the day they are born? Well, we're not there yet because we have not quite studied. 

But if everyone participates in this study. 

Right. And so the future now is that let's get the women in to actually know what we need to do about screening. And then a decade from now, who knows what we'll be talking about. 

And every woman should know to stay healthy, the same things that keep you healthy are the same things that reduce your breast health risk. Exercise a lot. Eat more of a plant-based diet. Don't drink too much alcohol. 

Don't smoke. 

Don't smoke, of course. And join the WISDOM Study. 

And maintain a healthy body weight. But I'm going to tell a little story here on the panel that I remember meeting Dr. Olopade. I didn't meet her. I listened to her the first time 25 years ago and she talked about BRCA risk. And I will share that-- you mentioned it briefly in passing-- there probably will come a day in the not too distant future, I think, when we will be doing routine genetic testing on newborns and we will do what we call population-based screening. 

And what the research is now showing us that in women with breast cancer who may not have all of the risk factors, they too are showing up with some of these abnormal genes that may have predicted the risks. So the question then becomes where are we going to go in the future? Not quite there yet, but Dr. Olopade has been a leader in that thinking. And I give you all the credit for that because you once took me to task recently for not agreeing, but I'm coming around to your way of thinking. So that's a true confession. 

Keep working on it. 

More for the people that need it and less for the people that don't because if somebody has high risk, doing more is good. People for low risk, more is not better. It's just more, and sometimes more can be worse. That's why we need to modernize our approach. 

Yeah, the reason why I really think that research really moves us forward and why we encourage and we're asking everyone to join research, there's fundamental discovery that needed to be done. That's how BRCA1 and BRCA2-- all these genes had to be discovered and they were discovered. And then now that those genes, we know how they function, we need to now find out how do they function in human beings, how do they cause disease, and what can we do to prevent disease? 

So the benefit of research is what we are now saying is that we now know a lot more. And because we now know a lot more because we are curing more cancers, because we're helping more women with cancer, we now even want to move the needle even farther. And that's why we're talking about risk prediction, so that in the future, even if you knew you had a BRCA1 the day you were born, you would say, oh, that's OK because I know what to do and I will be fine. 

And that's where we want to get to. That's why we're really looking to have more women participate in the WISDOM Study, to have more families who have high risk identified, and then for us to join the movement to prevent cancer. And in this case WISDOM has a platform that would help us get to better prevention for women. 

Well, that was fascinating. Thank you very much. You guys were great. 

Thank you. 

That was interesting. We are out of time. That's all the time we have for At the Forefront Live today. I want to thank our guests for being here to discuss this very important study. I also want to thank you for watching and submitting your great questions. If you want to know more about the WISDOM Study or would like to be part of the study, make sure you visit wisdomstudy.org. I promised we would have it back up there. Wisdomstudy.org is where you need to go. 

We'll have another At the Forefront Live scheduled for later this week. It's about liver disease and liver transplant. Please make sure you join us Friday, January 25th at 12:30 to learn all about the liver and liver disease. And finally, make sure to check our Facebook page often to see the schedule for At the Forefront Live. There's also lots of other great information there as well. Thanks for watching. We hope you have a great week.

A longstanding debate has stymied the medical community about when and how often women should be screened for breast cancer. The WISDOM study will assess whether personalized screening is as safe, effective and accepted compared to annual screening.

This week to discuss we were joined by:

Olufunmilayo Olopade, MD, and Tara Gehring, RN

Breast Cancer Care

Our team represents expertise across the spectrum of breast cancer care: breast imaging, breast surgery, medical and radiation oncology, plastic and reconstructive surgery, lymphedema treatment, clinical genetics, pathology and nursing. Patients receive a comprehensive treatment plan that optimizes chances of their survival and quality of life.

Learn more about UChicago Medicine breast cancer care.