Mammography Is Essential and Quality Matters with Dr. Janet Storella
about the episode
Sharon is joined by Dr. Janet Storella, Medical Director of Breastlink Maryland at RadNet. Dr. Storella is a breast imaging specialist and a board-certified diagnostic radiologist with over 40 years of radiology experience.
In this conversation, Dr. Storella shares deeper insight into the practice and art of mammography, contemporary issues in the field, spaces for improvement, and aspects of mammography where quality makes all the difference.
There are differing opinions on when women should start annual mammography screening, but Dr. Storella emphasizes that understanding one’s risk factors is key to determining when to start screening and collaborating on a personalized plan with their doctor. She highlights how diagnostic imaging centers are working on lowering barriers to compliance, particularly through strategic partnerships like RadNet’s with Walmart.
Dr. Storella shares that determining if a mammogram shows cancer can be extremely difficult because of the variable nature of breast tissue. She expands on her experiences using AI to interpret test results and the journey to convincing insurance companies to cover this impactful new practice. Even though mammograms are continuously critiqued by doctors and patients alike, Dr. Storella reminds us that ultimately mammograms save lives, help individuals detect cancer earlier, and are what we have available right now.
Finally, Dr. Storella explains the technical factors that contribute to high-quality breast imaging and why an uncomfortable mammogram is a positive sign of adequate compression. She also highlights the rigorous standards that mammography technologists are required to meet, reinforcing her message that breast cancer screening is an advanced and highly artful skill.
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“On a mammogram, a tumor is going to be a white spot. Depending on the density of your underlying breast tissue, that background can be relatively black if you have a lot of fatty tissue. Then the thing stands out like a light bulb. The more dense tissue you have, the more white it is. Then you’re looking for the white tennis ball on a field of snow. That’s hard.”
About Dr. Janet Storella
Dr. Janet Storella is board-certified in diagnostic radiology and spent her residency at Beth Israel Hospital (Harvard Medical School). She earned her medical degree from Case Western Reserve University School of Medicine in Cleveland, Ohio, and her undergraduate degree in biochemistry from Harvard College. She has a special interest in breast imaging and helped introduce several pioneering technologies such as digital mammography and image-guided breast biopsy to the D.C. area. She was also named Bethesda Magazine's 2023 Top Doctor!
Connect with Dr. Storella on LinkedIn: Dr. Janet Storella
Episode Outline
00:53 Introducing Dr. Janet Storella
01:32 Chapter 1: Mammography Demystified
08:07 Chapter 2: The Power of AI to Amplify Breast Cancer Detection
12:09 Chapter 3: Quality Matters
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Sharon Kedar 00:02
Behind every pioneering idea, method, and device is a fellow human or humans. A trailblazer who is daring enough to ask the questions that push the boundaries and make the impossible possible. I'm Sharon Kedar, co-founder of Northpond Ventures, a multibillion-dollar science-driven venture capital firm, and the host of Innovate and Elevate. In each episode, we'll have candid, in-depth conversations with top doctors, scientists, and innovators about leading-edge discoveries and how they impact our lives. Season one focuses on women's health, with the aim of helping women lead our healthiest lives. You'll hear from leading experts such as Dr. Kathryn Rexrode, division chief, Women's Health at Harvard's Brigham Hospital. It's time for all of us to innovate and elevate.
Sharon Kedar 00:53
Our guest today is Dr. Janet Storella. Dr. Storella is board-certified in diagnostic radiology and spent her residency at Beth Israel Hospital, part of Harvard Medical School. She earned her medical degree from Case Western Reserve University of Medicine and her undergraduate degree in biochemistry from Harvard College. She has a special interest in breast imaging and helped introduce several pioneering technologies, such as digital mammography and image-guided breast biopsy to the DC area. Dr. Storella, welcome to the podcast.
Dr. Janet Storella 01:28
Thanks for having me.
Sharon Kedar 01:33
What's fascinating is the current standard of care. The first step for a disease which is, for one in eight women, getting breast cancer, is annual mammography screening from - I guess the age has moved around, so I'll ask you about that in a moment. What's fascinating is you're asking someone to go in, get their breasts smooshed; the more uncomfortable, the better. But make sure you don't forget to come back in 12 months once you're at a certain age.
Dr. Janet Storella 02:04
Right.
Sharon Kedar 02:04
Awesome.
Dr. Janet Storella 02:05
And do it all over again. I know. There's been a lot of controversy about mammography. Obviously, I've studied all this literature. It comes up every single year at the big medical conferences, both of all the radiologists, of all the breast imagers, of all the primary care docs, of all the OB/GYNs who are often the ones who are ordering mammograms. Some of it is controversial because it's been based on very flawed data and the like.
Dr. Janet Storella 02:33
I don't think that there is any question that screening mammography saves lives and that it results in decreased mortality from breast cancer. Nobody will argue that earlier detection is not a better thing than later detection, even if the mortality number might be the same. Do you want to have chemotherapy or not?
Sharon Kedar 02:53
No.
Dr. Janet Storella 02:55
You might live as long, but those are endpoints that we need to think about as well. So screening mammography is what we have right now. Yes, we have other modalities. They all have their role. But this is what we have right now.
Sharon Kedar 03:11
What age do you recommend people starting annual screening mammography?
Dr. Janet Storella 03:16
I'm a proponent of starting screening mammography at age 40. There are some very high-risk groups who maybe should be starting earlier. Is it the end of the world that you don't start? No, it's not. And by the way, this is not like there's some cliff at 40, or a cliff at 50. The incidence of breast cancer pretty much rises linearly with age. There's no drop-dead spot. This is all balancing how many people do you need to screen for how many cancers can you find, and is that acceptable in terms of how many people may have to have biopsies or other things.
Dr. Janet Storella 03:56
Are there fewer women in their 40s who get breast cancer as women in their 70s? Of course. But this is something of a sliding scale. What I tell people is don't get all wrapped up in this. I'm not talking about the people who are at especially high risk or special situations. For just average women, start getting a mammogram at age 40. Oh, you're 50 and you didn't do it? Don't beat yourself up. Let's go ahead and do it. This is not about judging people, this is about doing what you can for improving your own health.
Sharon Kedar 04:27
I saw that you opened in a Walmart, which I thought was cool.
Dr. Janet Storella 04:30
Yes, RadNet has a partnership with Walmart. This is part of bringing the resource to women, to make it easy for them. I'll be very interested to see how this works out. Do we find that we have much higher compliance rates and find cancers through screening? But this is matching the resources to where the risk is.
Sharon Kedar 04:52
Dr. Storella, why is a tool that is over a hundred years old, meaning mammography, why is that our primary tool for such an important disease that impacts so many women?
Dr. Janet Storella 05:05
It's maybe not quite over a hundred years old. I think xeromammography was developed in the '60s. The X-ray, yes, we're going back to Roentgen and the 1890s, but maybe to the '60s. You know, it's a good question. And, you know, we're looking at different kinds of imaging that we have, and there are different tools. There is ultrasound, there is MRI. I think that, again, it's a thing of resources and availability. MRI, in terms of imagining, MRI is the most sensitive method we have right now in imaging.
Sharon Kedar 05:41
I have many questions. I want to touch on what you said about how cancer and not cancer can look the same, and it's hard to tell the difference. Can you share with the viewers and listeners a little bit more about what you mean? If someone is going to get breast screening, how do they know if they're going to a doctor who is going to make the right call?
Dr. Janet Storella 06:05
On a mammogram, a tumor is going to be a white spot. Depending on the density of your underlying breast tissue, that background can be relatively black if you have a lot of fatty tissue. Then the thing stands out like a light bulb. The more dense tissue you have, the more white it is. Then you're looking for the white tennis ball on a field of snow. That's hard. There have been significant advances with digital mammography and what is now called 3D tomosynthesis that help us scroll through the density of the tissue to see better. That helps, but this is an art form, and it requires judgment. That's what makes it difficult.
Sharon Kedar 06:47
You just said that mammography is an art form. I think that is mind-blowing, and I would assert that most people have no idea that it's an art form. I think most people think it's like going to McDonald's and buying a hamburger.
Dr. Janet Storella 07:04
Not at all. One of the huge advances, and we can talk about this more as we go on, is artificial intelligence. What I tell people about artificial intelligence is that every day as I am looking at mammograms, I am making hundreds of judgments. The obviously abnormal things are obvious, and the obviously normal things are obvious. Then there's everything else that I like to call the murky middle. This is where judgment comes in.
Dr. Janet Storella 07:32
A lot of women ask, "Why can't you just read my mammogram right this minute?" I don't want to read your mammogram in a rush while I know you're waiting to pick up your kids and this and that. I want to look at your mammogram in peace and quiet, without distractions. I want to be able to develop a rhythm of looking at cases and focusing my attention. Trust me, it is much better for someone to batch-read your mammogram the next day than to be trying to do it on the fly if you're having a screening exam.
Dr. Janet Storella 08:07
What does artificial intelligence do? It directs my attention, and it helps grade all this gray zone into, this looks pretty darn suspicious; that, not so much. Don't worry about that. I find it incredibly helpful. The artificial intelligence that RadNet has, which is a company that we bought called DeepHealth, and that we did all the training and validation. Then it was subsequently evaluated for FDA approval. It showed that everybody got better. This is unheard of when you're doing these kinds of studies. Everybody got better. Expert breast imagers got better. Generalists who don't specialize in mammography got better. Everyone got better.
Dr. Janet Storella 08:50
At detecting cancer?
Dr. Janet Storella 08:51
At detecting cancer, yes.
Dr. Janet Storella 08:53
Wow.
Dr. Janet Storella 08:54
At detecting cancer.
Sharon Kedar 08:55
I know that for screening mammography, AI was approved something like in the past year, and it's not yet for diagnostic, which I'd love to understand more about and get your perspective. Is AI available for screening mammography at most centers? Or is RadNet unique in what you acquired?
Dr. Janet Storella 09:18
We have an FDA-approved product, and this is available. Unfortunately, we have to charge for it. We started out by thinking we're going to show the insurance companies how great this is and how many more cancers we're detecting, and they're going to want to pay for it. They were like, "Uh, no." That was mind-blowing. Very similar to 3D tomosynthesis in mammography, to start, we had to charge patients. Then a whole body of data was developed saying, number one, this works. Number two, people want this. So you should develop a code for this and pay for this. That's how payment for 3D tomosynthesis came about. It’s the same process we're going through right now with artificial intelligence.
Sharon Kedar 10:06
How much is it to pay for AI if a patient comes in?
Dr. Janet Storella 10:09
$40.
Sharon Kedar 10:10
$40 extra.
Dr. Janet Storella 10:12
I wish we didn't have to charge for it.
Sharon Kedar 10:14
Of course, of course. Do most people pay for it?
Dr. Janet Storella 10:16
Right now, in our area, about 40% of people are paying for it.
Sharon Kedar 10:22
More broadly, if you're not going to a RadNet facility, this technology is not available elsewhere? Or it is?
Dr. Janet Storella 10:30
Well, it is available in some places, and there are other products out there. I don't know too much about who has them and what they are. Obviously, the academic sites are all developing AI, and they may well be using it. You can always ask. "Where are you going? Do you use artificial intelligence in the interpretation of screening mammograms?"
Sharon Kedar 10:51
The callback rate is considered a negative, so if you have a higher callback rate, that is a negative in terms of monitoring?
Dr. Janet Storella 10:59
You're looking for a sweet spot. The sweet spot is calling back enough women to find cancers, not calling back too many that you have lots of false positives and unnecessary biopsies. Not calling back too few that you don't find cancers. So, we're all looking for a sweet spot of our callback rate versus our cancer detection rate.
Sharon Kedar 11:24
What's amazing as a lay person about that is one in eight women get breast cancer. While the survival rate is high, nobody wants breast cancer. It's horrible. I think sometimes folks talk about the survival rate, but it's like, have you ever talked to someone who's been through breast cancer? It's a terrible, terrible thing to have. When you talk about this sweet spot, I think about early detection being the magic that saves women. It's fascinating that you have to drive to that sweet spot. Early detection is the holy grail.
Sharon Kedar 12:07
When it comes to the technician doing the mammography, which I really don't know how much people appreciate what the whole procedure is like. Do you find the technician makes a difference? I know that personally I've been to your practice, and the technician was not messing around. It was like, if you can't breathe, it was a positive sign. "Hold your breath. Move your head. Freeze."
Dr. Janet Storella 12:36
"Hold your breath. Turn your head this way." Right. Listen, I wish that we didn't have to do mammography. I wish we had something else. But right now, this is what we have, and yeah, it's uncomfortable. It's no fun. The technologists are very well-trained, but they're people. They have different personalities, they have different styles. Again, part of our getting accredited is we have to submit images to the ACR to show that our technologists are adequately positioning patients to include as much breast tissue as they possibly can on the exam. We get scored on that.
Dr. Janet Storella 13:16
I tell my technologists, “I'm sorry, you didn't get enough muscle back here. You're going to have to bring this person back.” I also try to tell them when they do a great job, and I say, “Hey, this is an ACR-worthy case. I could send this off for accreditation. This is a gorgeous, beautiful case, right? You did a tremendous job here.” Women come in so many different shapes and sizes and heights, and this is difficult, okay? This is really, really hard. Of our technologists, I would say these women are really dedicated.
Sharon Kedar 13:46
Oh, they're heroes. They're heroes.
Dr. Janet Storella 13:49
They really care, and they get a lot of grief from everybody around them all day long. Please be nice to my technologists. They're trying to be nice to you but still perform at a standard that I expect of them because they know if they show me a case and I say, “No, you didn't get enough muscle here. Why is there no inframammary fold here?” They know that I'll tell them. So again, sweet spot.
Sharon Kedar 14:12
Yeah. Does more compression generally equate to better imaging?
Dr. Janet Storella 14:17
By and large, yes. There is inadequate compression, so the tissue all bunches up on top of itself, and it makes it look like there are lumps when there are no lumps. But there's a point where you get adequate compression. Again, there are so many different shapes and sizes of women and texture of tissue. This is an art form as well, and I trust my technologists to know when they're getting adequate compression.
Dr. Janet Storella 14:43
We measure it. It's on the image. It says how many pounds or decanewtons of compression there was. I will look at that, and I'll look at a case and think, God, this looks fuzzy. And I'll say, oh my god, five pounds. That's not enough compression. So there are these many additional technical factors that go into producing a mammographic image and getting a very high-quality mammographic image that you probably have no idea about as you're heading in for it. You're just thinking, oh my god, they're going to squash me.
Sharon Kedar 15:17
Thank you for tuning in. Please connect with me, Sharon Kedar, on LinkedIn for additional innovative content. If you enjoyed this episode, please take a moment to like it, and don't forget to subscribe to the channel by clicking the button below this video.
Sharon Kedar 15:35
The views and opinions of the host and podcast guests are their own professional opinions and may not represent the views of Northpond Ventures.
About Your Host
Sharon Kedar, CFA, is Co-Founder of Northpond Ventures. Northpond is a multi-billion-dollar science-driven venture capital firm with a portfolio of 60+ companies, along with key academic partnerships at Harvard’s Wyss Institute, MIT’s School of Engineering, and Stanford School of Medicine. Prior to Northpond, Sharon spent 15 years at Sands Capital, where she became their first Chief Financial Officer. Assets under management grew from $1.5 billion to $50 billion over her tenure, achieving more than 30x growth. Sharon is the co-author of two personal finance books for women. Sharon has an MBA from Harvard Business School, a B.A. in Economics from Rice University, and is a CFA charterholder. She lives in the Washington, DC area with her husband, Greg, and their three kids.
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