Ep 110: Pregnancy Associated Breast Cancer with Dr. Kristin Robinson

Ep 110: Pregnancy Associated Breast Cancer with Dr. Kristin Robinson

Nicole: And just a quick note, we had a little trouble with the audio on this episode. So forgive me that it's not the usual quality, but I promise that the content is still great. In this episode, you're going to learn about a really important topic, pregnancy associated breast cancer and breast imaging in pregnancy and while lactating. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello. Hello. Welcome to another episode of the podcast. This is episode number 110. I'm so grateful that you're spending a bit of your time with me today. On this episode, we have Dr. Kristin Robinson. Dr. Robinson is a board certified radiologist who specializes in breast imaging. She's a wife of almost nine years to a wonderful husband and a new mom to a five month old baby boy and a fur mom to two awesome French Bulldogs. Dr. Robinson's passion is educating women about their breast health, including breast density and personal breast cancer risk to help women make informed decisions about breast cancer screening. She believes knowledge is power. Yes, yes, yes. Now Dr. Robinson reached out to me because she learned some alarming statistics recently about breast cancer for women in their thirties. And she felt like the podcast would be a great platform to share important information about breast cancer and breast imaging, as it relates to pregnancy, lactation and younger women.

Nicole: And I 100% agree. We have a really informative conversation about pregnancy associated breast cancer, different types of imaging of the breast, what happens if you have a suspicious breast mass, mammogram recommendations, specifically recommendations for women who need a mammogram before age 40 and much, much more so really informative conversation. Now, obviously I don't want to alarm you with a topic. Breast cancer and pregnancy or associated with pregnancy is not common, but it does happen. I've had two patients in my career who have had breast cancer associated with pregnancy. One was a personal patient of mine at the, when I was at the time, still practicing in the office and in the postpartum period, she had noticed a breast mass and it didn't feel particularly suspicious to me. However, I always send folks who for imaging, if they have a breast mass, and in this particular case, it ended up being breast cancer, but it was caught early.

Nicole: So her prognosis was great. And then the second patient, wasn't a personal patient of mine. However, I was kind of peripherally involved in her care. And unfortunately in her case, her breast cancer was discovered a lot later than when she first had symptoms. So again, it's not common, but I do want you to know about it because it does happen. And breast cancer is one of those things. If it's caught early, the prognosis for treatment is really, really good. Now, one of the things we will talk about in the episode is how important it is to advocate for yourself. You know, I talk about that lots and lots and lots. And in the setting of birth, a great way to advocate for yourself is to have a birth plan. I have a fantastic free online class called How To Make A Birth Plan That Works.

Nicole: It's a one-hour class, it's on demand. And in this class, you'll learn how to get your doctors and nurses to pay attention to your birth plan, tips on approaching the process and much, much more. You see making a birth plan is not about filling out a template or a form online or anything like that. Making a birth plan needs to be a process to help you make sure you have the things in place so that you can have the birth that you want, including making sure you have a supportive provider and a supportive hospital environment. So you know about the team of folks who is there to support you. Those are the two things that will influence your birth almost more than anything. And that's exactly what I teach you in this free class. So sign up for the class its drnicolerankins.com/register. Again, it's about an hour long on demand. You can take it when it's convenient for you. All right. Let's get into the episode with Dr. Kristin Robinson.

Nicole: All right, well, thank you so much, Dr. Robinson for agreeing to come onto the podcast. I'm super excited to have you on. This is a difficult topic, but one that we needed to talk about, nonetheless.

Kristin: Absolutely. I'm so excited to be here. Thank you for having me

Nicole: Start off by telling us a bit about yourself, your work and your family, if you'd like.

Kristin: Sure. So, um, my name is Dr. Kristin Robinson. I am a board certified radiologist. Uh, I specialize in breast imaging and that's essentially all that I've practiced currently. I, um, am a Mayo clinic physician at the Jacksonville campus. And I did my residency training at the Mayo clinic in Arizona. I've been with Mayo for a long time and really love the group that I work with and the institution in general, I, um, am a new mom to an almost five month old little boy who is just the light of my life. And its just so neat watching him grow every day and change. Um, I've been married to my husband for almost nine years and we have two French Bulldogs who are the original babies, of course share the spotlight a little bit now. Uh, but nonetheless, everybody keeps us really busy.

Nicole: Yeah, for sure. Well, that was kind of a big change thing cause you all were married for a while before you added this other person to them.

Kristin: Exactly. It took us awhile to get pregnant kind of long stories, successful IVF one. Um, but even before that we were married for several years, so it's good. We had a lot of alone time, a lot of growing time together. Um, but it definitely makes for a big change from the routine that we've been used to for a long time.

Nicole: Yeah. Yeah, for sure. For sure. Well, how did you decide to come to focus specifically on breast imaging? And did you have any additional training in that as well?

Kristin: I did. So I actually started out, um, my residency training in general surgery. I yeah, big switch. Uh, I fell in love with general surgery during my third year of medical school rotations. Um, and then matched into a residency program for general surgery, but ultimately around the second year kind of realized that that wasn't the right path for me, uh, for an entire career. And, um, I will say though, my favorite specialty in general surgery was breast surgery. I fell in love with it. I love the patients, helping women. The pathology is very interesting to me. There's so much multi-disciplinary approach to care in, in breast cancer therapy. And so I really loved all of that. Um, so when I transitioned into radiology, it's no surprise that I stuck with breast imaging, uh, from there. And so I completed my diagnostic radiology residency and then did a, essentially a breast imaging fellowship or a women's imaging fellowship after that.

Nicole: Gotcha, gotcha. That can be a hard choice to switch specialties afterwards.

Kristin: Yes. The hardest choice I've made in my life probably about anything, honestly.

Nicole: Yes, yes. But I can honestly say that. I don't think I've ever seen anybody who's regretted it. Like it's better to just stop if you're not happy and then to keep going in something that you're not happy.

Kristin: I thought I would miss it. It was hard to imagine not being in surgery and afterwards I just, I really didn't. And so it was the best choice, but a very difficult one.

Nicole: Yeah, for sure. So one of the reasons you reached out is that also, although breast cancer is not very in women in their thirties, it's actually a leading cause of death for women in their thirties. And it's not infrequent that this cancer is diagnosed in association with pregnancy. Is that, is that correct?

Kristin: True. So I recently learned that breast cancer is the leading medical cause of death in women in that age group, which was shocking to me, um, being in that age group myself and recently pregnant, you know, all these things kind of run through your mind and it's not something you want to think about during pregnancy, which is typically a very happy time, but at the same point, it's critical to be aware that this diagnosis exists so that if something comes up, you know, a woman gets evaluated appropriately and doesn't push it off.

Nicole: Yeah, for sure. Yeah. Really, really important. So what exactly is pregnancy associated breast cancer?

Kristin: So pregnancy associated breast cancer is defined as breast cancer that is diagnosed either during pregnancy during the first postpartum year, and sometimes during lactation is also considered pregnancy associated breast cancer.

Nicole: Okay. Okay. And how common is it?

Kristin: It's rare. So it is about one in 3000 to 10,000 pregnancies. So I know that's a big range, but generally speaking, it's very rare. Um, it represents about 3% of all breast cancers that are diagnosed and we are unfortunately seeing an increase in it because it's a little unclear exactly why, but one of the main thoughts is because women are tending to delay childbearing nowadays career other reasons. And so as childbearing gets into the late thirties and sometimes even forties, uh, this can be more common today.

Nicole: Gotcha. And how frequently, you know, it sounds, it's, it's rare, but like, you know, 4 million women give birth in the U S so it's actually, you know, can, the number can start to creep up. So how many cases do you see yourself in a year? Roughly?

Kristin: So we, you know, Mayo clinic has just typically a little older population in that we don't have obstetrics here at my campus, we don't have obstetrics in Arizona. Um, so usually when we're seeing them, it's typically during the postpartum or the lactation period that said, we still see probably a handful of cases per year. And yeah, I would imagine if you're, you know, at a hospital where you've got an active OB practice, you're going to see more of them.

Nicole: Yeah. Yeah. So what then are some risk factors for pregnancy associated breast cancer?

Kristin: The data suggests that age over 35 during pregnancy is probably the main risk factor. Um, again, because it is rare, there are studies out, they aren't huge. We don't have a lot of data. Some other studies show that possibly delivering via cesarean birth can be a risk factor. The mec it's a little unclear why mechanism is exactly known, but it might have something to do with oxytocin hormone levels in the body. And perhaps those are lower in women who have given birth via cesarean. Um, and then breastfeeding, if you do, or don't do that, the oxytocin levels, you know, different there too. So the papers that I was reading a little, a little unclear if that's the cause, but in some bigger studies where there were hundreds of thousands of patients looked at, um, that was a risk factor that was seen. And then another risk factor is possibly having multiple pregnancies, as opposed to just only having your first kind of crime at pregnancy. Oh, that's interesting. Yeah. So the data is a little equivocal, um, because we don't have a lot of big high volume studies, but that, that those are the risk factors that you can find out.

Nicole: Gotcha. Gotcha. So how does it usually present, I guess, or how is it detected and maybe those are two different questions, but I guess how do, how do women usually present with, um, with, with pregnancy associated breast cancer?

Kristin: They actually are this about the same here. So most women are going to present or it's going to be detected by a palpable mass. So it actually feels a mass in her breast. Um, part of that is really, I think most likely because this age group, we aren't screening, you know, our recommendation for an average risk woman is to start mammograms at age 40. And so if most women are getting pregnant in their twenties and thirties, we just aren't catching them from a screening standpoint yet. So unfortunately it's usually when a woman actually feels something in her breast. Okay.

Nicole: Okay. So say she is pregnant or recently had a baby feels something in her breast and then, um, goes to the doctor. I should say, let me first ask, are there any masses that would be more concerning or do you think like every time you feel something in this period that it should be imaged kind of, what are your thoughts?

Kristin: It's really tricky. I think anyone that has been pregnant or breastfeeding knows the breast change a lot. They grow, they become lumpy bumpy, they're painful. So doing the breast exam on yourself can be challenging that said, Oh, you know, we always say still be breast aware. Um, kind of, you know, don't not do them, but just really kind of try to be overall, have a good sense of what your breast feels like even through all the stages, pregnancy and breastfeeding. So that said more concerning masses are the same as in a woman who's not pregnant and not breastfeeding, usually a mass that's really hard or fixated kind of against the chest wall. Um, those are the things that we're most worried about. Benign masses tend to be mobile, kind of squishy. Um, usually a benign mass is going to have more pain associated with it. Although sometimes cancer can present with some pain.

Kristin: Um, and then I would say that the ones that tend to be more benign too, are the ones that kind of fluctuate throughout either the day or a couple of weeks. You know, if you're, if you're breastfeeding and you're really engorged and you have that kind of ropey band-like tubular kind of shaped mask that goes away after you breastfeed, you know, those are the ones probably more related to changes from being engorged or um, that type of thing. So the scary ones are the ones that, you know, usually are the culprits are hard and fixated and they really don't change.

Nicole: Got it. Okay. Now, is there any reason to not do breast imaging during pregnancy? I feel like sometimes just in general radiology, there's a lot of sometimes hesitancy, especially on the part of radiologist, even when we order studies to do imaging for fear of harming the pregnancy. So is there a reason not to do any imaging during pregnancy?

Kristin: You know, there really isn't, it, it should be done. Um, which imaging you choose is what's important here, but there are enough modalities that we can do it safely. And so I just, at least from my perspective and the way I was trained, you know, taking care of the woman is priority and we can really figure out ways to do it safely for her baby too.

Nicole: 100%. Like, unfortunately not all of your colleagues is see it that way. Sometimes

Kristin: I know, it's frustrating. I'm like why?

Nicole: Yes. And it's like, we have to take care of mom in order for baby to be healthy. Um, so just like if it needs to be done, it needs to be done. Now, speaking of the different types of images, there's mammography, there's ultrasound, there's MRI. Can you walk us through what each one is, how each one works? When are they used?

Kristin: Absolutely. So in the pregnancy and usually with breastfeeding too, not always though, if a woman comes in with a concern in her breasts, we're almost always going to start with ultrasound. So ultrasound uses sound waves to look into the breast and look at the tissues, same ultrasound that we use to look at baby, of course, and you know, anywhere else in the body. Um, the probe that we use and the gel is kind of the medium of how we use the sound waves. And so there's no radiation. Um, at this point, you know, we don't know of any harm to the fetus, but within reason, some technical factors I could get into that are way beyond the scope of what we did talk about. But for the most part, ultrasound is very, very safe. And so that is what we start out with in this, um, you know, kind of group that would be coming to see us if you're pregnant.

Kristin: And typically if you're breastfeeding also then as far as the next one so mammography, uh, this is our work horse for sure in non-pregnant patients. And we do screening mammograms. Um, so mammogram, it uses very low dose radiation to look at the breast tissues. And nowadays most practices have moved to doing 3d mammograms. So not only is it the low dose radiation, but we're looking at individual slices of the breast with it, which is really neat because then it just gives us a lot more detail. Um, so that can definitely be done when a woman is breastfeeding, there is no danger from a radiation standpoint to doing that. The confounding factor is that the breasts become, uh, very dense. They become a little bit more difficult to analyze with the mammogram because of that when a woman is breastfeeding. So that's why that's our first go to for the most part.

Kristin: Um, but it's definitely something that we do often for breastfeeding patients for pregnant patients. We would not do a mammogram unless we saw something highly concerning on the ultrasound. So if we do do a mammogram in a pregnant woman again, it's cause we're very concerned about what was seen on the ultrasound. We need to look further at the breast and we can actually shield the baby by putting a lead apron on the belly. Um, and so that almost makes the radiation completely negligible to the fetus, even without putting all that apron on, you know, the radiation or concentrating it on the breast. So we aren't concentrating or even imaging tummy or baby at all. And so the radiation dose, even without an apron is extremely low. Um, well, well, well below what's considered safe radiation exposure to a fetus what's considered safe for, you know, radiation workers like myself, if you were pregnant, you know, exposed to some radiation here and there.

Kristin: So, um, mammograms are well below that. So that can be done in pregnancy. It's not common to do it again, unless there's a concern, but we certainly could. Gotcha. And then MRI. So MRI is a little bit trickier, um, in order to make it useful, to see the breast, we have to use contrast medium, it's called gadolinium. So that's injected in a vein. It basically helps us assess different areas of blood flow in the breast. And that is contraindicated or not safe to use in pregnancy because we know it crosses the placenta. We don't have a lot of studies on what it does once it gets into the placenta, but it's not something we really want to study. And so as a whole, we just say, no MRIs of the breast with contrast when a woman is pregnant, we can do it when breastfeeding again, because it's, there's no risk then obviously there's no, there's no baby to worry about. So we could certainly do that when a woman is lactating and in general MRI, it just, it's a magnetic resonance imaging, same as an MRI, anywhere else in the body, it uses really strong magnets to manipulate the tissues and turn them into an image for us through some very complicated physics, but incredible modality. It just, yeah, that is one that we would not do when a woman is pregnant.

Nicole: And what about CT scan?

Kristin: So CT is also something that we would not typically do when a woman is pregnant, unless the circumstance was really necessary. And there's a few considerations I can think of that are not related to breast. So in general, we do not evaluate breast with CT. It doesn't have high enough resolution for us to actually see the tissues, how we need to see them. So we don't have to worry about CT from a breast standpoint, there are certain indications if a woman had other issues like pulmonary embolism or something like that in the emergency department, maybe that would be worth doing a CT. Um, but in general, the CT is not something we do in pregnant patients. Yeah.

Nicole: Gotcha. And would you say it's fair to say, and I know we're talking about, um, breast imaging, but you're a radiologist. So I just want to ask in general, like if, just to reiterate, if there's a study or a test that needs to be done, that's going to give us information about mom's health, then we should do it while mom is pregnant.

Kristin: I can't blanket statement and say yes, but my initial gut is yes. If that makes sense. So like you said before, mom being healthy is what is, what's going to keep baby healthy. And in general, our, um, really radiology practices have gotten so good and our imaging has gotten so good at using the lowest doses of radiation for everything that we do pregnant or not. And so the small doses of radiation associated with medical imaging nowadays, um, it's very safe. And so if we ever had to do something where, you know, we had to do like a CT for mom, again, issue of brain injury or something that was affecting her life-threatening ability to breathe, something like that, you know, then, um, the decision would likely be made that that is what, you know, the small radiation dose could do to a baby.

Nicole: Got it. And it's typically only like, well, not repeated imaging, it's usually like a one-time sort of thing. Yeah, yeah, yeah. Yeah. So if a woman needs to have some sort of breast imaging during pregnancy or while breastfeeding, what should she expect?

Kristin: So it depends what it is that you've got going on. Again, most women are going to feel something, lump or bump. Some women are going to have pain, rarely women have nipple discharge. You know, that isn't milk that might be bloody, that we need to work up. Those types of things. We pretty much are always going to start with an ultrasound in either scenario for the most part, that way, if we see something worrisome or a mass with the ultrasound, the radiologist will make the determination. If he or she thinks a mammogram is going to be useful next. Okay. So those are usually done on the same day in the same appointment. So you come in with your concern, you get looked at with the ultrasound, by the technologist, the radiologist is going to look at those images, probably come in and assess you him or herself with the ultrasound. And then if there's something that, um, is worrisome there, they might recommend a mammogram to look at that further. Uh, so usually it kind of goes in that, that path.

Nicole: Okay. And then if there's anything there that looks suspicious, especially for cancer, will the radiologist biopsy it?

Kristin: Yes. So, um, oftentimes we see masses in a woman who's pregnant or lactating that are not cancer, or we can't tell. And so we tried to err on the side of caution and typically, um, if a biopsy is needed, it is done by the radiologist. And we do biopsies all day every day. So we have a lot of experience with them. Um, they're needle biopsies, they're done all under local anesthetic just with the numbing, like lidocaine, they're in, in and out procedure. Um, no sedation is needed. So again, if you are pregnant, you don't have to worry about taking something, you know, systemically that might end the baby. The lidocaine is very safe to use in pregnancy and lactation. So the biopsy itself is definitely something that we can do safely. Okay.

Nicole: And so it's a pretty, pretty quick, it's not like a major, you know, like cutting a huge chunk out or anything like that. It's just a small sample of tissue.

Kristin: Yup. Small sample of tissues sent to the pathologist and get the results. Um, so again, we do them so often they're tolerated really, really well. And that way it just kind of puts us all at ease. If we see something we're not sure about, we can just biopsy it and make sure, um, and you know, um, in the uncommon circumstance that it does come back a malignancy, then we have an answer and we know that we need to do more.

Nicole: Gotcha. Gotcha. So you, a woman could potentially expect to get an ultrasound and, or maybe a mammogram and a biopsy all at the same appointment if need be. So, or would you have to come back for the biopsy?

Kristin: Usually usually come back for the biopsy. Some practices are set up to kind of do same day, um, diagnostic workup, we call it and, uh, in a biopsy, but most practices I think are set more for diagnostic imaging one day and then biopsy planning and biopsy on a different day.

Nicole: Okay. Okay. How long do you typically have to wait, would you say in between like being took? Cause I know that can be a little bit anxiety in between, like, when you've been told that you have this suspicious area and then when you can come back for a bio.

Kristin: Yeah. It really depends on the practice and the volume, but I think most of the time we we're cognizant of this and we really try to get women in within a week or so two at the most. Um, it just depends a little bit on everybody's schedule, you know, the patient included. So, um, Oh, and you know, one thing I should mention, just so no, one's surprised that they ever are breastfeeding and need some imaging. We like you to pump for future babies right. Before whatever we do. Yeah. The, the, again, the tricky part about analyzing of breasts during all, this is just how much extra tissue and fluid is there. And so if you can empty the milk as much as possible, it can help reduce some of that density. We see, you know, with the mammogram and even with the ultrasound. So, um, I just did a biopsy on a pregnant woman probably a week or two ago. And I had our nurse, you know, call her the day before, as soon as they saw I was doing this and said, please bring your pump or bring your baby. I know it's COVID, but we want to try to get, get that milk out. However we can. Don't be surprised by that. It's a little unusual, but that is what we typically recommend women do.

Nicole: Okay. That's good to know. That's good to know. And then how long does it typically take for the biopsy results to come back?

Kristin: You know, every center is going to be different. Um, we're, we're pretty blessed here. We do our biopsy turn around in a couple of days, I think, Oh, centers, I feel like usually about a week or so. Um, so it just really depends on the clinic that you go to and what the setup is for pathology, because we have it all on site. So ours is, they're pretty quick. They're awfully quick actually. Yeah. Usually a couple of days here. Okay.

Nicole: Okay. And will it be, and I guess it also varies like will, you know, people will tell you whether they'll call you or have you come back or all of those kinds of things in terms of follow-up.

Kristin: So at Mayo clinic, um, what I've seen at both of the sites that I've worked at is our primary care providers or whoever's referring the patient typically communicates biopsy results. Um, that sent though again, when we have young patients that they've got an OB who doesn't work here or somewhere else, any patient really, I asked them if they're comfortable with me telling them results directly, as soon as I get them just to, uh, you know, cut down on having to fax the results to the provider's office and the provider has to see them and they have to call the patient. Um, you know, I know I can deliver the results within a couple of days as opposed to having to wait. So most women are really accepting of that and happy for the quicker turnaround. So, um, it's not unusual for me to be calling patients with results when, you know, we try to get it to them as soon as possible.

Nicole: Gotcha. Gotcha. And would you, would you also say that it's important to, I know some places like, have we gotten away, I guess from the like no news is good news strategy and just making sure that the results are communicated one way or the other, do you think it's fair to say like, definitely like talk to somebody or see the results yourself

Kristin: A hundred percent. Absolutely. Um, radiology for breast imaging in particular, we are highly regulated by the FDA under something called mammography quality and standards app. So we actually as radiologists follow up on every biopsy that we do and we assess something called concordance, meaning I look at the images, I have an idea in my mind, but I think it's going to be, and I know what I will accept it to be or not. And so when I get those biopsy results, if it goes along with what I was thinking, then I consider that concordance and we put that in our reports. We actually make an addendum to every biopsy that we do. And we either say that we've communicated these results to the provider directly, to the patient directly, or they're available in their chart, you know, and it's a Mayo clinic patient. Um, or if the biopsy comes back something I'm surprised about when I say, gosh, I was really, that was really suspicious to my eyes and my experience, and this came back benign, I just am not really comfortable with that.

Kristin: Then we might say, Hey, you know what, let's either do another biopsy or a surgical biopsy or do something else to follow this and that we would call this concordance. So that's something that's a little unique to breast imaging. Um, there are a few centers. We have to do that for our biopsies, but I think it really helps to close that loop for patient care. You know, so we know that we know exactly what that was. We agree with it, we're okay with it or we're not. And then that's communicated either to the provider than to the patient or directly to the patient, you know? So, um, I feel like the patient, you should definitely hear your results and make sure you understand what they showed and that there's nothing else that needs to be done from an additional imaging or followup standpoint.

Nicole: That is really important to know. I honestly did not know that there were those extra levels. Um, it would be like by law because mammography,

Kristin: You know, it's because I think we do such wide widespread screening. And so everything we do is highly regulated in breast imaging.

Nicole: Wow. Well now I knew, I know all about the dense breast and like having to put those sort of disclaimers and things in there, but I didn't know about the biopsy results. That is good to know. And its reassuring actually.

Kristin: Yeah, it should be because again, it keeps all of us on our toes and aware of what we've done. It's great learning for all of us, you know, cause sometimes something doesn't look that suspicious and you biopsy it cause you're just not sure when it comes back cancer, it's like, wow, all right, now, now I know what to do in the future. Again, it's a really good feedback mechanism too.

Nicole: And speaking of if cancer is diagnosed, obviously that's outside of what you do. But typically I know it gets to be a multi-disciplinary effort, particularly in young young folks, if they're pregnant, um, especially about how to treat things. So it's gonna trigger a whole cascade of things to happen. Right?

Kristin: Absolutely. And you know, again, this is not my area of expertise, but that said pregnant patients can absolutely be treated for breast cancer. It's pretty amazing actually, what can be done typically, not during first trimester, but, uh, second and third trimester surgery can happen. Chemotherapy can happen all without, you know, ill effects to the baby. And so it's not something that a woman should put off because she thinks, well, if they found something, they can't do anything anyways. So why do I want to know, go and have that mentality? You know, the sooner you know what the answer is, the quicker you can be treated, hopefully the less of the stage, like it hasn't spread anywhere, all these reasons to get worked up because with modern medicine and therapies that we have, we can do a lot at any kind of stage during pregnancy and then certainly postpartum.

Nicole: That's really good to know. Really, really good to know. And then the last thing I want to say is, or ask is, um, you talked about how mammography isn't recommended and this even goes back and forth until 40 age 40, who are some women that might need a mammogram before age 40, because that's, who's the most people in my listening audience. I would love for you to share some recommendations about that.

Kristin: Yes. And I would love to talk about this because again, it's really hard to educate, um, and capture young women about these issues. And so this is just such a great platform to do it. So essentially Mayo clinic, we follow the recommendations from the American college of radiology. So I know you talk a lot about ACOG Obstetrics. And so ACR is our kind of society, our governing and for radiology and, uh, ACR recommends that women age 40 and above get a mammogram every year, if you are at average risk. So risk is kind of a topic in and of itself, but generally speaking, you might start to wonder if you are a above average risk. If you have a certainly a genetic mutation in you or a family member that predisposes you to breast cancer. So I think the most common ones people know about are the BRCA mutations, the VFC mutation one. And number two. So if you or a family member has that, you may be at elevated risk of developing breast cancer, other women, as far as elevated risk. If you have a first degree relative that has had breast cancer, you're going to want to start doing your screening mammograms 10 years earlier than the affected relative's age.

Nicole: Got it. And first degree is defined as

Kristin: Yeah. So mom, sister, daughter, and actually, I should say parent because men get breast cancer too. So if you have dad that had breast cancer or a brother, um, they would count as well.

Nicole: Perfect. Okay. So if you have the, if you have the BRCA mutation or at risk for, and I guess who would be at risk for it, or why would you even get tested for it? Does that go along with having family members who may have had it at a younger age?

Kristin: Exactly. So most women, you know, breast cancer in general, not related to pregnancy, but in general has typically been considered a post-menopausal, um, type of cancer post-menopausal disease. So women who have had breast cancer diagnosed premenopausal, those are the ones that start to get extra screening and start to get extra tests because we want to see if there is some type of genetic mutation that they have that may have contributed to that breast cancer. And then if you have a family member or a family history of breast cancer with multiple relatives, either on one side or both sides, there may be some genetic predisposition to getting breast cancer. Even if you have a genetic test and it's negative, you still would be probably considered higher risk. And so you're gonna want to start screening mammograms potentially earlier than age 40. And here at Mayo clinic, we have a breast clinic that has a high risk clinic, where essentially we have a few providers who specialize in this and they see women and they plug all of this information, your, um, your age, how many children you've had, your breast density, family members with breast cancer into risk calculators.

Kristin: And it gives out a lifetime risk percentage. So when I talk about risks, eventually that's what you're going to probably get is a risk assessment. And depending on what that percent shows you're considered either high-risk, above average risk, or average risk. Um, but until a woman actually gets to that stage and gets to, you know, the risk assessment, if you have that genetic mutation or family members, first degree relatives with breast cancer, you want to kind of start thinking, okay, wait a minute. Could I be high-risk and definitely talk to your doctor about that.

Nicole: Gotcha. Gotcha. And then would you also say, or is it fair to say that if a younger woman, you know, under 40 and you have a mass that is persistent or it's growing, don't let it get sort of written off, um, just make sure it gets like imaged or evaluated in some way. Do you feel like that's fair to say?

Kristin: Yes. Sometimes patients really need to advocate for themselves. Maybe, you know, more often than not. I hope it's not as often, but, um, yes. You know, you know, your body better than anybody, you know, your body better than your doctor, who's doing a self breast exam. So, um, if you feel something and you're worried about it, please get evaluated. And if you're not getting the response that you want and you really think something should be done, then push for that. Because really these exams the mammogram, ultrasound, very, very safe something we can easily do in, you know, a morning or an afternoon and get you some good answers. So it is definitely worth persisting if you have a problem.

Nicole: Yeah. It always breaks my heart. When you hear stories of like, I had this thing for awhile and I was told, Oh, it's nothing to worry about. So yeah. Yeah. So just to wrap up, and these are questions that I ask everybody who comes on, what is the most frustrating part of your work?

Kristin: That what you just said is actually one of the most frustrating things, it kind of goes to both. Some patients we see that have had something, you know, an abnormality, a mass in their breast and put off, coming to get evaluated for lots of reasons, fear, certainly one, some women are caregivers for elderly parents or children with special needs, just not focusing on themselves for many good reasons, not to, but they put it off. And then by the time they come and see us things are certainly further along in a bad way than had to be when I first noticed it. And then on the flip side is the woman who had done everything. Right. You know, she, she felt something, she went to her doctor. I mentioned something, sometimes it's even gotten imaging and just the diagnosis wasn't made when it, maybe it could have been like what you mentioned earlier, dense breast tissue on a mammogram can hide a lot things. And so it can really confound our ability to diagnose sometimes. Um, but you know, those just break your heart when for whatever reason, you know, something's been there and we just couldn't get to it sooner.

Nicole: Yeah, for sure. For sure. So then on the flip side, what's the most rewarding part of your work?

Kristin: I, there are so many rewarding things that I just, I feel really blessed to have, um, to have this job and to be in this career. I, you know, when you mentioned dense breasts, that's actually, one of my passions is educating women about their breast density and, um, screening and supplemental screening to mammograms because as radiologists, we want to do the best we can and find breast cancer as little as early as possible. Um, and so I've had a lot of breast density conversations with women and kind of explaining what it means and what the implications are and what we can do about it. And, um, for some women, they're, they're very anxious about the topic, you know, they got this report or this letter talking about it from their doctor and they're confused. And so when in general, when you get to talk to a woman and actually explain what's going on with her breast and her breast imaging, and you see that anxiety or that fear turn to understanding and some confidence and some empowerment, um, I love that where you just, you know, you've helped that person advocate for themselves going forward.

Kristin: And so I think that's one of the most rewarding parts of what I get to do

Nicole: And that sounds really rewarding for, so it's always nice when you can help bring people some peace of mind and some clarity about something. Yeah. Yeah. So then last thing, what's your favorite piece of advice either as a doctor or as a mom yourself that you'd like to give to expectant moms?

Kristin: Oh goodness. There are so many things. Cause I listened to your podcast all through my pregnancy. And even after to be honest with you, when I go on my runs, I'm like, all right, what's Dr. Nicole up to today. So, so I know you asked this question and I know what a lot of women say is you can't plan or, you know, and I don't want to be the one that just keeps saying that, but now having had my first child and been labor and delivery, it is so true. And that's why everybody says it. And I had visions of this calm and peaceful and spiritual birth. And we had a doula and I wanted low intervention. I probably talked ad nauseum with my doctor about all these things that I had hoped for. And ultimately like all went out the window, not right away, but, um, you know, probably about five centimeters in.

Kristin: So that said, I still had a wonderful experience. I felt really supported. I felt really informed going into my labor and birth that helped me, even though my plans changed, I still, everybody knew what I wanted and I still knew how to help advocate that. And I had a doctor that I really aligned with, you know, his way of practicing and what I had hoped for. And he was just so amazing. They're all of it. So that I think is important. Um, regardless of what ends up happening, the more informed you are, the better and that way, you're not, you know, wondering what if, um, on the back end of things. Um, so that's for the pregnancy and birth part. And then I just have to put a plug in if for breastfeeding. So if a woman is breastfeeding, if you want to breastfeed and you think you're going to have to pump, I thankfully discovered like a wearable breast pump.

Kristin: This is a game changer. So I would say invest in one, if you're even interested, try it. Um, I pumped at Costco last week. I pumped. Yes, it's so amazing. It is amazing. I pump on walks with my dogs when, if the baby's with the nanny and like, I just need to get outside with them for two seconds. You can do it anywhere. I do at work multiple times per day. And so that was a game changer that I try to tell everyone about. I'm such a huge proponent of breastfeeding. So there's two on the market. And I actually have no stock in either of these, the Willow and the LV. I have the Willow, that's just what a bunch of my friends had. So that's kind of what I went with. Um, but it literally sits in your nursing bra that you probably already are wearing right now. And, um, the pump and the container fit in there. So you just pull your shirt down, you look like Dolly Parton when you have it on. But other than that, it's overall really discreet otherwise. And so the milk just collects in those containers. You take it off, empty it out and you're good to go. So that has been a lifesaver. So I almost gave up on breastfeeding at like the six week mark about this thing and it really turned it all around.

Nicole: Oh, well, that is good to know. I learn something new every day. They certainly did not have that around for me, but, um, I'm old. So

Kristin: Not yet. I mean, I don't even think this thing was around a few years ago. All the technologists I work with have seen me pumping and they're like, wait, you're doing what.

Nicole: Right, right, right.

Kristin: I went and talked with a patient with this pump on.

Nicole: And it's not noisy or anything?

Kristin: I mean, if it's really quiet in the room, you can tell something's happening, but you know, it isn't it isn't so noisy. Like when my colleagues are in the station next to me, I don't think people are hearing it and whatnot. So.

Nicole: Okay. Pretty cool. I love it. Love it, love it. So where can people find you?

Kristin: I am one of those weirdos that does not have social media personally.

Nicole: That's not weird

Kristin: Be a productive use of my life, but, um, I just haven't really taken that plunge yet.

Nicole: Don't do it.

Kristin: All my friends are like now that you have the baby. I'm like, Oh my goodness. I don't know. Maybe one day, but so I think the best place is we've got a social handle for our Mayo clinic cancer center and that's @mayocancercare. And then to reach out to me personally, too, I mean, that will be checked and I can certainly get back to you on that. Or, um, my administrative assistant has graciously offered to accept phone calls if anyone wants to buzz in. And so that phone number is (904) 953-2447. Oh. That was really nice to you.

Nicole: Well, thank you so much for coming on this information is without a question going to be helpful. And I know I certainly learned a lot, so I appreciate you reaching out and being able to chat with you about this.

Kristin: Thank you for having me, like you said, in the beginning, you know, it's, it's not a topic that I think a lot of women want to hopefully ever face, but even think about sometimes when it's such a beautiful time in your life, but at the same point it's so, so important.

Nicole: Yup. Yup. For sure. For sure. Well, thank you again.

Kristin: All right. Thank you.

Nicole: Right. Wasn't that a really informative episode? She obviously has a passion for her work and I so appreciate her coming on to share this important information with all of us now, you know, after every episode, when I have a guest on, I do something called Nicole's Notes. So here are my Nicole's Notes from my conversation with Dr. Robinson, number one, take a lesson from how she changed her career from general surgery to radiology, don't stick with something that you know is not right. And I want you to apply that to your pregnancy care provider. If your doctor is not meeting your needs, then find another provider. It is almost never too late to do so. And I have never seen anyone regret changing from a doctor who was not right for them. Sometimes it can feel weird because you went to that person, your whole pregnancy, or even before your pregnancy, but please, if it's not a good fit and then find someone else, you will not regret it.

Nicole: And in fact, you will be glad that you've made that change, if you needed to. Number two, the most important part of having a healthy baby is having a healthy mom. I totally understand where there may be a hesitation for things like x-rays or medications in pregnancy, but again, you cannot grow a healthy baby if you are not healthy yourself. And although I understand it's perfectly natural to ask, you know, how does the medication effect your baby? Or how does the test affect your baby? Please know that we're never going to recommend anything that we think would endanger your pregnancy. That is what we are here for. We are looking out for both mom and baby during pregnancy. So we're not going to recommend anything or give you a medication or tell you to get a study that we think would be harmful to your health or baby.

Nicole: Of course we are, you know, should discuss the risk and benefits and everything. But no, in general, we're not going to recommend something that we know would hurt your baby. That's just not what we do. Okay. So make sure that you are healthy in order for your baby to be healthy. And that also continues postpartum. All right, whether that is self care, taking a moment for yourself, whether that's taking care of any postpartum depression or anxiety in order for you to raise a healthy baby, grow a healthy baby, raise a healthy baby, mom needs to be healthy. So don't be afraid. Don't be, feel like you're selfish for focusing on your health because that's really important.

Nicole: Number three, do ask to see all of your lab and ultrasound report results. Don't definitely don't go with a no news is good news approach. Okay? You want to physically see those things so you can look at them, ask questions if need be. Now in a lot of instances or in most instances, I should say there are electronic patient porters, patient portals, where you can see your own lab results. Now, the thing about these patient portals is there was recently some legislation passed and it made it so that lab results will automatically populate to patients without a physician seeing them, including abnormal lab results. Now, this is good in the sense that you can get your lab results pretty quickly and immediately when they are available and you can see them for yourself, however it's bad in that sometimes they result whenever they result, that could be a Sunday afternoon and it could be a normal result or it can be an abnormal result.

Nicole: Okay. And that can cause a lot of anxiety don't expect that on a Sunday afternoon, you know, or at midnight, when you check something, when your results come back, that you're going to get a response from your doctor. We're just not there 24 seven in order to address those types of concerns. Now, of course it's reasonable, the next day is to call the office and ask to get a response about the results and, you know, set up an appointment or talk to someone. But please don't expect that when results come back at odd times or over the weekend, that you're going to be able to get some confirmation or discussion, right. Then you're going to have to wait until office hours. That's one of the downsides of lab results coming back at kind of these random times. All right, now, again, it shouldn't be like days or weeks or anything like that, but just be mindful that when those results come back, we can't always physically address them right away.

Nicole: Because again, they come back sometimes weird hours. All right. Okay. And then the last thing I want to say is don't dismiss a breast mass. I personally, when I was in practice in the office, you know, I don't practice in the office anymore. I practice as a hospitalist. So I only work in the hospital, but when I was in the office and whenever someone had a palpable breast mass, I always sent people for imaging. It's very low risk and it gives a lot of information and can, can potentially give a lot of reassurance. So if you have a breast mass, don't dismiss it, err on the side of caution, have it imaged just to be safe and make sure you know that everything is okay. All right. So there you have it. Please subscribe to the podcast, wherever you're listening to me right now, that may be Spotify.

Nicole: That may be Apple Podcasts that may be Google Play. It may be Amazon. It may be wherever because now you can get podcasts wherever these days. And I would really love it. If you leave a review in Apple Podcast in particular that helps the show to grow. I do shout outs from those reviews from time to time, also helps other women find the show. And I've just loved reading what you think about the show. And don't forget to sign up for my free online class, How To Make A Birth Plan That Works. You will get a step by step process in order to help you understand what really needs to go into the process of making a birth plan. It is so much more than just filling out a template or a checklist. That class is completely free. You can sign up for it at drnicolerankins.com/register. So that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth.

Nicole: Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.