Welcome to Stuff You Missed in History Class, a production of iHeartRadio.

Welcome to Stuff You Missed in History Class, a production of iHeartRadio.

Hello, and welcome to the podcast. I'm Tracy V.

Hello, and welcome to the podcast. I'm Tracy V.

Wilson and I'm Holly Frye.

Wilson and I'm Holly Frye.

Back at the end of twenty twenty three, I had more mammograms than has been typical for me so far in my life. I know, going back for additional imaging is a routine experience for some folks, and it can be really scary. For me, this was a new experience. Ultimately, everything was fine, but of course all of that made me think about where this all came from. And we have also gotten some requests for a history of mammography over the years.

Back at the end of twenty twenty three, I had more mammograms than has been typical for me so far in my life. I know, going back for additional imaging is a routine experience for some folks, and it can be really scary. For me, this was a new experience. Ultimately, everything was fine, but of course all of that made me think about where this all came from. And we have also gotten some requests for a history of mammography over the years.

While I was.

While I was.

Working on this, I was astonished at how much of it happened during hollyson My lifetime. Like I had sort of imagined my grandmother's going to get a baseline mammogram in some kind of old timey mammography machine in the fifties or early sixties. There were not even old timy mammography machines at that point. Uh. And something I want to be super clear about from the top of the show is that we are going to be talking about some of the recommendations on who should get a mammogram and when, and some questions and controversies about mammography and other kinds of breast imaging. This is not medical advice. Holly and I are not doctors. Please do not especially avoid getting a mammogram based on our summary of debates about it from the seventies or whatever like.

Working on this, I was astonished at how much of it happened during hollyson My lifetime. Like I had sort of imagined my grandmother's going to get a baseline mammogram in some kind of old timey mammography machine in the fifties or early sixties. There were not even old timy mammography machines at that point. Uh. And something I want to be super clear about from the top of the show is that we are going to be talking about some of the recommendations on who should get a mammogram and when, and some questions and controversies about mammography and other kinds of breast imaging. This is not medical advice. Holly and I are not doctors. Please do not especially avoid getting a mammogram based on our summary of debates about it from the seventies or whatever like.

No, that's for a doctor discussion.

No, that's for a doctor discussion.

There are still debates, they are ongoing. My advice is, I know this is hard, especially in the United States, but try to find a provider you trust and discuss it with them. Yes.

There are still debates, they are ongoing. My advice is, I know this is hard, especially in the United States, but try to find a provider you trust and discuss it with them. Yes.

The history of mimography begins with the discovery of X rays. In November of eighteen ninety five, Wilhelm Conrad Runkin was experimenting with a Crooks tube. This is a type of cathode ray tube, named for Sir William Crooks, who was one of several people to develop similar tubes in the eighteen sixties and seventies. This was a vacuum sealed container made of glass with electrodes allowing a current to pass through it that would cause the tube to glow.

The history of mimography begins with the discovery of X rays. In November of eighteen ninety five, Wilhelm Conrad Runkin was experimenting with a Crooks tube. This is a type of cathode ray tube, named for Sir William Crooks, who was one of several people to develop similar tubes in the eighteen sixties and seventies. This was a vacuum sealed container made of glass with electrodes allowing a current to pass through it that would cause the tube to glow.

Uh. That is not the most precise explanation of what this was, but I feel like we're not a physics podcast, So It's okay. Runkin's discovery is often described as accidental, but he was intentionally experimenting to try to figure out if the Crooks tube was emitting something other than visible light. He had placed an opaque wrapper around the tube, and when he started the current to make sure that rapper was blocking out all the light, some very un platino cyanide on a piece of cardboard several feet away started to glow. So you could describe that one moment as an accidental discovery because he was basically checking on his setup when he noticed this glow, but it was in the context of a deliberate investigation. He had been studying light phenomena for a while. The accident was that he got data back sooner than he expected.

Uh. That is not the most precise explanation of what this was, but I feel like we're not a physics podcast, So It's okay. Runkin's discovery is often described as accidental, but he was intentionally experimenting to try to figure out if the Crooks tube was emitting something other than visible light. He had placed an opaque wrapper around the tube, and when he started the current to make sure that rapper was blocking out all the light, some very un platino cyanide on a piece of cardboard several feet away started to glow. So you could describe that one moment as an accidental discovery because he was basically checking on his setup when he noticed this glow, but it was in the context of a deliberate investigation. He had been studying light phenomena for a while. The accident was that he got data back sooner than he expected.

To write. Soon, Runkin realized that whatever the cathodeery tube was emitting could affect a photographic plate in addition to passing through the shroud he was using to block the visible light. These mysterious rays seemed to pass right through various substances, including a plywood door, but they were blocked by a strip of beating that had been stuck to the or with lead. When he put his wife's hand in front of the photographic plate. The resulting image clearly showed her bones and the rings she was wearing.

To write. Soon, Runkin realized that whatever the cathodeery tube was emitting could affect a photographic plate in addition to passing through the shroud he was using to block the visible light. These mysterious rays seemed to pass right through various substances, including a plywood door, but they were blocked by a strip of beating that had been stuck to the or with lead. When he put his wife's hand in front of the photographic plate. The resulting image clearly showed her bones and the rings she was wearing.

That image, of course, is often described as the first X ray. Runkin reported his discovery at the end of December, using the term X rays because the nature of these rays was at the time unknown. Today we know that X ray radiation is part of the electromagnetic spectrum, with a higher frequency than visible or ultraviolet light. By mid January eighteen ninety six, so almost immediately after Runkin made his announcement, doctors and researchers were finding medical and dental uses for X rays, like producing images of broken bones, foreign objects in the body, and teeth. Most soft tissue doesn't show up well on an X ray, but soon doctors had figured out that they could X ray the digestive system if the patient ingested a contrast agent like barium sulfate. He also figured out that controlled exposure to X rays could treat certain cancers. Runkin was awarded the Nobel Prize in Physics for his discovery in nineteen oh one, and the field of radiology is also called runkinology. For years, X ray images were also known as Runkin photographs. But of course, at this point people didn't have a clear sense of how long exposure should be, or how best to position people, or the damaging effects of too much radiation exposure. Accounts from the first years after Runkin's discovery describe exposure times of thirty minutes or an hour, or, in the case of William Levy in July of eighteen ninety six, a whole series of exposures lasting from eight in the morning until ten at night. This was done at his requests. They were trying to locate a bullet that had been in his head since being shot by a bank robber ten years before. Although doctors did obtain a good image of the bullet, Levy was one of many patients who was harmed by this radiation exposure. His whole head became blistered and swollen, he lost all of his hair on one side, and his lips cracked and bled. Other patients also experienced things like burns and hair loss, and a number of practitioners who were exposed to X ray radiation over the course of years developed cancer later in their lives. While there were medical uses for X rays, pretty much immediately after their discovery, it took some time before researchers tried to X ray breast tissue. The first person known to have done this is Albert Solomon, who was working at the University Hospital in Berlin. He studied tissue from three thousand breasts, and some accounts that I read described this as coming from patients who had had mastectomies. Others described it as tissue that had come from the morgue. I could not find a scan of this publication anywhere in any language. I am not clear on the details.

That image, of course, is often described as the first X ray. Runkin reported his discovery at the end of December, using the term X rays because the nature of these rays was at the time unknown. Today we know that X ray radiation is part of the electromagnetic spectrum, with a higher frequency than visible or ultraviolet light. By mid January eighteen ninety six, so almost immediately after Runkin made his announcement, doctors and researchers were finding medical and dental uses for X rays, like producing images of broken bones, foreign objects in the body, and teeth. Most soft tissue doesn't show up well on an X ray, but soon doctors had figured out that they could X ray the digestive system if the patient ingested a contrast agent like barium sulfate. He also figured out that controlled exposure to X rays could treat certain cancers. Runkin was awarded the Nobel Prize in Physics for his discovery in nineteen oh one, and the field of radiology is also called runkinology. For years, X ray images were also known as Runkin photographs. But of course, at this point people didn't have a clear sense of how long exposure should be, or how best to position people, or the damaging effects of too much radiation exposure. Accounts from the first years after Runkin's discovery describe exposure times of thirty minutes or an hour, or, in the case of William Levy in July of eighteen ninety six, a whole series of exposures lasting from eight in the morning until ten at night. This was done at his requests. They were trying to locate a bullet that had been in his head since being shot by a bank robber ten years before. Although doctors did obtain a good image of the bullet, Levy was one of many patients who was harmed by this radiation exposure. His whole head became blistered and swollen, he lost all of his hair on one side, and his lips cracked and bled. Other patients also experienced things like burns and hair loss, and a number of practitioners who were exposed to X ray radiation over the course of years developed cancer later in their lives. While there were medical uses for X rays, pretty much immediately after their discovery, it took some time before researchers tried to X ray breast tissue. The first person known to have done this is Albert Solomon, who was working at the University Hospital in Berlin. He studied tissue from three thousand breasts, and some accounts that I read described this as coming from patients who had had mastectomies. Others described it as tissue that had come from the morgue. I could not find a scan of this publication anywhere in any language. I am not clear on the details.

Solomon compared the tissue to the images shown in the X rays, and in nineteen thirteen he published a paper in German titled Contributions to the Pathology and Clinical Medicine of Breast Cancer and that describes how runken photographs could show the existence and spread of breast cancer, as well as revealed the presence of cancer that couldn't yet be felt through touch. Although soft tissue doesn't show up well on an X ray, breast cancer usually has a different density than the tissue around it, and some cancers also cause micro calcifications or calcium deposits. All of that is visible on an X ray To be clear. These were not very clear X rays at all, but they were there. Solomon's work was interrupted by World War One, during which he worked as a doctor with the German military. He returned to the hospital after the war was over, but in nineteen thirty three, as the Nazis came to power, he was removed from his position because he was Jewish. After the November Pogram, also called krystel Nacht, he was interned at a concentration camp and the family fled Germany after his release. His daughter Charlotte was sent to live with grandparents in southern France, but she was captured and killed at Auschwitz. Solomon and his wife were interned a second time, but escaped, and they survived the rest of the war by hiding in the Netherlands. They lived in Amsterdam after the war was over and Solomon went into private practice. He had had to recertify in medicine because his German credentials were not recognized there. Some other researchers worked with X rays and breast tissue during these years, but not until almost fifteen years after Solomon first published the first person known to take an X ray of a living person's breast was German surgeon Otto Kleinschmidt. In nineteen twenty seven, he was working under the direction of surgeon Edwin Peer.

Solomon compared the tissue to the images shown in the X rays, and in nineteen thirteen he published a paper in German titled Contributions to the Pathology and Clinical Medicine of Breast Cancer and that describes how runken photographs could show the existence and spread of breast cancer, as well as revealed the presence of cancer that couldn't yet be felt through touch. Although soft tissue doesn't show up well on an X ray, breast cancer usually has a different density than the tissue around it, and some cancers also cause micro calcifications or calcium deposits. All of that is visible on an X ray To be clear. These were not very clear X rays at all, but they were there. Solomon's work was interrupted by World War One, during which he worked as a doctor with the German military. He returned to the hospital after the war was over, but in nineteen thirty three, as the Nazis came to power, he was removed from his position because he was Jewish. After the November Pogram, also called krystel Nacht, he was interned at a concentration camp and the family fled Germany after his release. His daughter Charlotte was sent to live with grandparents in southern France, but she was captured and killed at Auschwitz. Solomon and his wife were interned a second time, but escaped, and they survived the rest of the war by hiding in the Netherlands. They lived in Amsterdam after the war was over and Solomon went into private practice. He had had to recertify in medicine because his German credentials were not recognized there. Some other researchers worked with X rays and breast tissue during these years, but not until almost fifteen years after Solomon first published the first person known to take an X ray of a living person's breast was German surgeon Otto Kleinschmidt. In nineteen twenty seven, he was working under the direction of surgeon Edwin Peer.

In nineteen thirty, radiologists Stafford Leake Warren at the University of Rochester in New York published on a technique that he had developed for compiling X rays taken from two different angles. To get a stereoscopic view of the breast, he had patients lie on their side with their arm raised above their head, sort of stretching out the tissue a bit. This stereoscopic view offered us somewhat more detailed and accurate look at density changes within the breast. Warren took X rays of the breasts of one hundred and nineteen patients who had already been diagnosed with some kind of breast issue and were scheduled for surgery. Using those images, he concluded that fifty eight of them had breast cancer. After their surgeries, he compared those results to the breast tissue that had been removed and confirmed that fifty four of those patients did have cancer. Four other patients had breast cancer that Warren had not detected through his X rays. Yeah, so basically there were four patients who he thought had breast cancer but did not, and another four that he had not thought had breast cancer but did. Other patients in Warren's study, rather than having had cancer, had chronic mastitis or benign tumors, absesses, some other issue that was not cancer, and Warren's paper detailed what these looked like in the X rays. This was pretty impressive, considering that the images in Warren's X rays were not very clear or detailed. Like if you look at a mammogram today and you don't know how to read it, I would say it can look not very detailed to you. These were very blobby, like just a lot of white blobs in vague shapes. A year after this, German researcher Walter Vogel published a paper on using X rays to differentiate between different types of tumors, including how to tell benign breast lesions from malignant ones. The term mammography was coined in nineteen thirty seven by Nymphis Frederic Hicken, a physician and surgeon in Salt Lake City, Utah. His article Mimography the rent Genographic Diagnosis of Breast Tumors by Means of Contrast Media was published in the Journal Surgery, Gynecology and Obstetrics. He was one of several people in the nineteen thirties and forties who were looking at the use of contrast media to get better images in breast X rays. Contrast enhanced mimography is still around today and it's typically used after someone has already had a mammogram without contrast, like if that mammogram showed something that required further investigation or to monitor progress during breast cancer treatment, especially in people who can't get an MRI for some reason. We will look into how mammography evolved in the nineteen forties and fifties after a sponsor break. If you have never had a mammogram. Today there is a machine involved, one that is made specifically for mimmography and it compresses the breast. But the researchers we've been talking about so far, we're using basic X ray equipment that had not been made specifically for breast imaging, and they also weren't compressing the breast tissue to X ray it. The first person known to compress the breast to try to get a better image of it was Raoul Lebourne, who was a radiologist from Uruguay in nineteen forty nine. He found that compressing the breast produced clearer images and made it easier to distinguish between cancerous and benign masses. He also found that using a double emulsion film improved the image quality even further. He described the presence of micro calcifications that could be used to help identify certain cancers. Lebourne started publishing his findings on all this in nineteen fifty one.

In nineteen thirty, radiologists Stafford Leake Warren at the University of Rochester in New York published on a technique that he had developed for compiling X rays taken from two different angles. To get a stereoscopic view of the breast, he had patients lie on their side with their arm raised above their head, sort of stretching out the tissue a bit. This stereoscopic view offered us somewhat more detailed and accurate look at density changes within the breast. Warren took X rays of the breasts of one hundred and nineteen patients who had already been diagnosed with some kind of breast issue and were scheduled for surgery. Using those images, he concluded that fifty eight of them had breast cancer. After their surgeries, he compared those results to the breast tissue that had been removed and confirmed that fifty four of those patients did have cancer. Four other patients had breast cancer that Warren had not detected through his X rays. Yeah, so basically there were four patients who he thought had breast cancer but did not, and another four that he had not thought had breast cancer but did. Other patients in Warren's study, rather than having had cancer, had chronic mastitis or benign tumors, absesses, some other issue that was not cancer, and Warren's paper detailed what these looked like in the X rays. This was pretty impressive, considering that the images in Warren's X rays were not very clear or detailed. Like if you look at a mammogram today and you don't know how to read it, I would say it can look not very detailed to you. These were very blobby, like just a lot of white blobs in vague shapes. A year after this, German researcher Walter Vogel published a paper on using X rays to differentiate between different types of tumors, including how to tell benign breast lesions from malignant ones. The term mammography was coined in nineteen thirty seven by Nymphis Frederic Hicken, a physician and surgeon in Salt Lake City, Utah. His article Mimography the rent Genographic Diagnosis of Breast Tumors by Means of Contrast Media was published in the Journal Surgery, Gynecology and Obstetrics. He was one of several people in the nineteen thirties and forties who were looking at the use of contrast media to get better images in breast X rays. Contrast enhanced mimography is still around today and it's typically used after someone has already had a mammogram without contrast, like if that mammogram showed something that required further investigation or to monitor progress during breast cancer treatment, especially in people who can't get an MRI for some reason. We will look into how mammography evolved in the nineteen forties and fifties after a sponsor break. If you have never had a mammogram. Today there is a machine involved, one that is made specifically for mimmography and it compresses the breast. But the researchers we've been talking about so far, we're using basic X ray equipment that had not been made specifically for breast imaging, and they also weren't compressing the breast tissue to X ray it. The first person known to compress the breast to try to get a better image of it was Raoul Lebourne, who was a radiologist from Uruguay in nineteen forty nine. He found that compressing the breast produced clearer images and made it easier to distinguish between cancerous and benign masses. He also found that using a double emulsion film improved the image quality even further. He described the presence of micro calcifications that could be used to help identify certain cancers. Lebourne started publishing his findings on all this in nineteen fifty one.

Lebourne wasn't using equipment made specifically for mammograms, though basically the person stood in front of a table that was about breast height. The breast to be x rayed was placed on the table with the photographic film in an envelope under it. Then there was a cone. The X ray emitter was at the little end and the big end was placed on the breast, applying what he described as a slight pressure. Lebourne used a small cone when a specific area of the breast needed to be imaged, and a large cone to image the whole breast.

Lebourne wasn't using equipment made specifically for mammograms, though basically the person stood in front of a table that was about breast height. The breast to be x rayed was placed on the table with the photographic film in an envelope under it. Then there was a cone. The X ray emitter was at the little end and the big end was placed on the breast, applying what he described as a slight pressure. Lebourne used a small cone when a specific area of the breast needed to be imaged, and a large cone to image the whole breast.

One of the other people working on breast imaging in the nineteen fifties was Robert Egan, who started his work during his residency in radiology. Over the course of his research, he concluded that mimmography could use lower power X rays than other diagnostic imaging did, and that radiologist could adjust the power based on breast size and density. He pinpointed a more sensitive X ray film that could provide more detailed images and intensifying screens that could reduce blurring. He also suggested the use of cardboard cutouts to position the breast for the best view. Like several other researchers before him, Egan x rayed the breasts of people who had been diagnosed with cancer or another breast disease, comparing the X ray image to the diagnosis they had already received. He also compared the X rays of that breast to the patient's other, presumably healthy breast. He sometimes detected tumors in the other breasts that the patient and doctor had not been aware of. Egan's initial focus had been on helping doctors visualize known or suspected cancers in order to make diagnoses and treatment plans, but his research also suggested that mimography could be used as a screening tool. Between nineteen fifty six and nineteen fifty nine, he and his colleagues at m D. Anderson Cancer Center imaged the breasts of a thousand patients who didn't have obvious signs of breast cancer, and in two hundred and thirty eight of them, mimography revealed a previously undetected tumor. Most of these tumors were so small that they could not be felt at all. One of them was only eight millimeters in diameter. Egan became a proponent of the idea of screening mammograms and later traveled all around the country training other radiologists to do them. There was even a national study to confirm that his techniques could be successfully taught to other people, who could then get similar results in the mammograms they performed. Egan was not the only one advocating for screening mammograms around this time. Others were Jacob Gershan Cohen, and Helen Ingleby. All through the nineteen fifties, Grushan, Cohen, and Ingleby collaborated on research related to the breast and breast imaging, including various ways that different pathologies could have here in an X ray, and they also documented normal changes to the breast due to factors like menstruation, lactation, and age, which were also visible on X rays. They published numerous papers together and co authored a book called Comparative Anatomy Pathology and wrote Ganology of the Breast that was published in nineteen sixty. So we'll take a moment here to note that we were about halfway through this episode on mimography and we have only just now gotten to a woman researcher. At this point, there were not many women doctors. There were even fewer women in specialized fields like radiology or oncology. We have a previous episode on Elizabeth Blackwell, who was the first woman in the US to earn an MD, which had happened in eighteen forty nine. Helen Ingleby had attended the London Medical School for Women, which was England's first medical school that enrolled women, and one of its founders was Elizabeth Blackwell. Ingleby was also one of the Saint George's Four, which was a nickname for the four first women to begin studying medicine at Saint George's University of London, which was in nineteen fifteen.

One of the other people working on breast imaging in the nineteen fifties was Robert Egan, who started his work during his residency in radiology. Over the course of his research, he concluded that mimmography could use lower power X rays than other diagnostic imaging did, and that radiologist could adjust the power based on breast size and density. He pinpointed a more sensitive X ray film that could provide more detailed images and intensifying screens that could reduce blurring. He also suggested the use of cardboard cutouts to position the breast for the best view. Like several other researchers before him, Egan x rayed the breasts of people who had been diagnosed with cancer or another breast disease, comparing the X ray image to the diagnosis they had already received. He also compared the X rays of that breast to the patient's other, presumably healthy breast. He sometimes detected tumors in the other breasts that the patient and doctor had not been aware of. Egan's initial focus had been on helping doctors visualize known or suspected cancers in order to make diagnoses and treatment plans, but his research also suggested that mimography could be used as a screening tool. Between nineteen fifty six and nineteen fifty nine, he and his colleagues at m D. Anderson Cancer Center imaged the breasts of a thousand patients who didn't have obvious signs of breast cancer, and in two hundred and thirty eight of them, mimography revealed a previously undetected tumor. Most of these tumors were so small that they could not be felt at all. One of them was only eight millimeters in diameter. Egan became a proponent of the idea of screening mammograms and later traveled all around the country training other radiologists to do them. There was even a national study to confirm that his techniques could be successfully taught to other people, who could then get similar results in the mammograms they performed. Egan was not the only one advocating for screening mammograms around this time. Others were Jacob Gershan Cohen, and Helen Ingleby. All through the nineteen fifties, Grushan, Cohen, and Ingleby collaborated on research related to the breast and breast imaging, including various ways that different pathologies could have here in an X ray, and they also documented normal changes to the breast due to factors like menstruation, lactation, and age, which were also visible on X rays. They published numerous papers together and co authored a book called Comparative Anatomy Pathology and wrote Ganology of the Breast that was published in nineteen sixty. So we'll take a moment here to note that we were about halfway through this episode on mimography and we have only just now gotten to a woman researcher. At this point, there were not many women doctors. There were even fewer women in specialized fields like radiology or oncology. We have a previous episode on Elizabeth Blackwell, who was the first woman in the US to earn an MD, which had happened in eighteen forty nine. Helen Ingleby had attended the London Medical School for Women, which was England's first medical school that enrolled women, and one of its founders was Elizabeth Blackwell. Ingleby was also one of the Saint George's Four, which was a nickname for the four first women to begin studying medicine at Saint George's University of London, which was in nineteen fifteen.

Ingleby was the first.

Ingleby was the first.

Woman to qualify for the Bachelor of Medicine degree at the university.

Woman to qualify for the Bachelor of Medicine degree at the university.

The lack of women in medicine absolutely affected the field of mimmography and the understanding of breast cancer and just breast health in general. There's still so much cultural baggage around breasts and around gender, and this was even more true in the nineteen fifties and sixties. A lot of male doctors were uncomfortable examining women patients breasts, and a lot of women were uncomfortable being examined by male doctors or even talking to a male doctor or anyone else about a concern with their breasts. Robert Egan was known to complain about the fact that cultural taboos and hang ups about breasts were getting in the way of medicine, and some of his colleagues gave him crude nicknames because of his focus on mimmography.

The lack of women in medicine absolutely affected the field of mimmography and the understanding of breast cancer and just breast health in general. There's still so much cultural baggage around breasts and around gender, and this was even more true in the nineteen fifties and sixties. A lot of male doctors were uncomfortable examining women patients breasts, and a lot of women were uncomfortable being examined by male doctors or even talking to a male doctor or anyone else about a concern with their breasts. Robert Egan was known to complain about the fact that cultural taboos and hang ups about breasts were getting in the way of medicine, and some of his colleagues gave him crude nicknames because of his focus on mimmography.

They're in the research for this episode. It also really stood out to me that Helen Ingleby had been a collaborator on work that really helped document the many ways that a person's breasts can change due to very ordinary things like menstruation and aging. With all of those changes being like in the umbrella of normal, I feel like she is the original consultant of like, no, yeah, that happens. No, that's that's not really yeah that happens all the time. Although Egan, Gershan, Cohen, and Ingleby were all vocal proponents of mimmography, not a lot of radiologists were actually performing mammograms by nineteen sixty. The nineteen sixty Annual Oration before the Massachusetts Medical Society, which was published under the title the Role of Diagnostic ron Geneology and Medicine in the New England Journal of Medicine does not mention mimmography or the breast at all. Egan had published his mimography technique by then, but most practitioners still didn't know about it yet. There was also no dedicated equipment to make X raying the breast easier and more consistent. Even formal research into mimography was still being done with X ray equipment that was made for other purposes, and the radiologists who were X raying the breast were mostly working with patients who were already showing signs of breast cancer or some other disorder or disease of the breast. This was not usually a way to spot previously undetected problems. Although there were anecdotes about people whose tumors had been discovered on a breast X ray, there had not been any controlled studies to determine whether mammograms could be used as an effective screening tool.

They're in the research for this episode. It also really stood out to me that Helen Ingleby had been a collaborator on work that really helped document the many ways that a person's breasts can change due to very ordinary things like menstruation and aging. With all of those changes being like in the umbrella of normal, I feel like she is the original consultant of like, no, yeah, that happens. No, that's that's not really yeah that happens all the time. Although Egan, Gershan, Cohen, and Ingleby were all vocal proponents of mimmography, not a lot of radiologists were actually performing mammograms by nineteen sixty. The nineteen sixty Annual Oration before the Massachusetts Medical Society, which was published under the title the Role of Diagnostic ron Geneology and Medicine in the New England Journal of Medicine does not mention mimmography or the breast at all. Egan had published his mimography technique by then, but most practitioners still didn't know about it yet. There was also no dedicated equipment to make X raying the breast easier and more consistent. Even formal research into mimography was still being done with X ray equipment that was made for other purposes, and the radiologists who were X raying the breast were mostly working with patients who were already showing signs of breast cancer or some other disorder or disease of the breast. This was not usually a way to spot previously undetected problems. Although there were anecdotes about people whose tumors had been discovered on a breast X ray, there had not been any controlled studies to determine whether mammograms could be used as an effective screening tool.

This started to shift later in the sixties, in part because the work of radiologist Philip Strax. His wife, Bertha Goldberg Stras had died of breast cancer in nineteen forty seven, the age of just thirty nine, and that led him to focus his career on the detection and treatment of breast cancer. In nineteen sixty three, he began collaborating with Sam Shapiro, director of Research and Statistics at the Health Insurance Plan of Greater New York or HIP or HIP, and surgeon Lewis Vney on a large scale, randomized trial into the efficacy of mimmography as a screening tool.

This started to shift later in the sixties, in part because the work of radiologist Philip Strax. His wife, Bertha Goldberg Stras had died of breast cancer in nineteen forty seven, the age of just thirty nine, and that led him to focus his career on the detection and treatment of breast cancer. In nineteen sixty three, he began collaborating with Sam Shapiro, director of Research and Statistics at the Health Insurance Plan of Greater New York or HIP or HIP, and surgeon Lewis Vney on a large scale, randomized trial into the efficacy of mimmography as a screening tool.

Uh, I'm just gonna admit I did not go down the rabbit hole of whether people say this hip or hip. We're just gonna call it hip. Participants in this study were HIP members, and sometimes this trial is called the HIP study. It involved sixty two thousand women between the ages of forty and sixty four. Half were given annual examinations that involved an interview, a breast exam, and a mammogram.

Uh, I'm just gonna admit I did not go down the rabbit hole of whether people say this hip or hip. We're just gonna call it hip. Participants in this study were HIP members, and sometimes this trial is called the HIP study. It involved sixty two thousand women between the ages of forty and sixty four. Half were given annual examinations that involved an interview, a breast exam, and a mammogram.

The other half.

The other half.

Received their usual medical care without this annual screening, although if their doctor gave them a breast exam or ordered them to get a mammogram for some reason, they were not prevented from getting one, they just were not having a dedicated annual screening. This was a three year study, and initially the death rate from breast cancer was reported as forty percent lower in the group that had received the annual breast exams. That number was later lowered to thirty percent, but that was still dramatic. Patients in the screening group who were diagnosed with breast cancer over the course of the study were also far more likely to show no signs of the disease in their lymph nodes, meaning their cancer was probably locally confined to the breast when it was detected. The study also acknowledged some of the realities of the medical system and getting access to medical care in the United States, like these were all folks who were part of a health insurance plan, that is a specific population of people. At the same time, many of the hospitals in New York where mammograms were being done were not convenient to the women who were enrolled in this study, so the team basically turned a van into a mobile mimography and they drove it to the places where the women worked so that they could be screened on their lunch break. Even with that effort, though, a significant number of participants in this study didn't return for their follow up exams. That reduced the number of people who participated in the study all the way to the end.

Received their usual medical care without this annual screening, although if their doctor gave them a breast exam or ordered them to get a mammogram for some reason, they were not prevented from getting one, they just were not having a dedicated annual screening. This was a three year study, and initially the death rate from breast cancer was reported as forty percent lower in the group that had received the annual breast exams. That number was later lowered to thirty percent, but that was still dramatic. Patients in the screening group who were diagnosed with breast cancer over the course of the study were also far more likely to show no signs of the disease in their lymph nodes, meaning their cancer was probably locally confined to the breast when it was detected. The study also acknowledged some of the realities of the medical system and getting access to medical care in the United States, like these were all folks who were part of a health insurance plan, that is a specific population of people. At the same time, many of the hospitals in New York where mammograms were being done were not convenient to the women who were enrolled in this study, so the team basically turned a van into a mobile mimography and they drove it to the places where the women worked so that they could be screened on their lunch break. Even with that effort, though, a significant number of participants in this study didn't return for their follow up exams. That reduced the number of people who participated in the study all the way to the end.

Preliminary results were published in the Journal of the American Medical Association in nineteen sixty six, and another article followed in nineteen seventy one, and overall, using mammograms to screen people for breast cancer seemed like a clear success. Philip Strax joined Robert Egan, Jacob Gershaan Cohen, and Helen Ingleby in advocating for screening mammograms.

Preliminary results were published in the Journal of the American Medical Association in nineteen sixty six, and another article followed in nineteen seventy one, and overall, using mammograms to screen people for breast cancer seemed like a clear success. Philip Strax joined Robert Egan, Jacob Gershaan Cohen, and Helen Ingleby in advocating for screening mammograms.

Another big breakthrough came about in nineteen sixty five in Strasbourg, France, when radiologist Charles Gross worked with company generald At Radiology to develop the CGR centograph. This was the first device specifically made to X ray the breast. Gross was a vocal advocate for breast cancer screening as well, and there are a number of sources that describe him and Philip Egan as the two people within the medical community who really did the most to push the idea of screening mammograms into the mainstream. Of course, there were also developments that were happening from outside the medical community. In the US, for example, President Richard Nixon announced a War on Cancer in nineteen seventy one. A year later, the National Cancer Institute and the American Cancer Society teamed up to launch the Breast Cancer Detection Demonstration Project or BCDDP. The American Cancer Society was heavily invested in this During the nineteen fifties and sixties, the American Cancer Society had pushed for routine cervical cancer screening using AP tests, and death rates from cervical cancer were declining. It was hoped that routine breast screenings would have a similar impact on deaths from breast cancer. The BCDDP offered five years of free annual mammograms to women over the age of thirty five. That was at twenty nine screening centers located in twenty seven cities around the US. More than two hundred and eighty thousand women were screened at one of these centers between nineteen seventy three and nineteen eighty That exceeded the project's initial goal by more than ten thousand.

Another big breakthrough came about in nineteen sixty five in Strasbourg, France, when radiologist Charles Gross worked with company generald At Radiology to develop the CGR centograph. This was the first device specifically made to X ray the breast. Gross was a vocal advocate for breast cancer screening as well, and there are a number of sources that describe him and Philip Egan as the two people within the medical community who really did the most to push the idea of screening mammograms into the mainstream. Of course, there were also developments that were happening from outside the medical community. In the US, for example, President Richard Nixon announced a War on Cancer in nineteen seventy one. A year later, the National Cancer Institute and the American Cancer Society teamed up to launch the Breast Cancer Detection Demonstration Project or BCDDP. The American Cancer Society was heavily invested in this During the nineteen fifties and sixties, the American Cancer Society had pushed for routine cervical cancer screening using AP tests, and death rates from cervical cancer were declining. It was hoped that routine breast screenings would have a similar impact on deaths from breast cancer. The BCDDP offered five years of free annual mammograms to women over the age of thirty five. That was at twenty nine screening centers located in twenty seven cities around the US. More than two hundred and eighty thousand women were screened at one of these centers between nineteen seventy three and nineteen eighty That exceeded the project's initial goal by more than ten thousand.

Interest in screenings also surged in the US in the fall of nineteen seventy four after Betty Ford, wife of President Gerald Ford, and Margaretta Rockefeller, known as Happy Wife of Nelson Rockefeller, each announced that they had been diagnosed with breast cancer. Although neither of their cancers had been initially detected in a mammogram, both underwent surgery and survived, and their public acknowledgment of what had happened helped dispel some of the stigma and secrecy surrounding the disease.

Interest in screenings also surged in the US in the fall of nineteen seventy four after Betty Ford, wife of President Gerald Ford, and Margaretta Rockefeller, known as Happy Wife of Nelson Rockefeller, each announced that they had been diagnosed with breast cancer. Although neither of their cancers had been initially detected in a mammogram, both underwent surgery and survived, and their public acknowledgment of what had happened helped dispel some of the stigma and secrecy surrounding the disease.

It was also evolving that breast cancer was a survivable and even curable disease if people caught it early, and this was feeding into that as well. Things moved a bit more slowly in other parts of the world. For example, in Europe in the nineteen seventies, only Sweden and Scotland conducted trials of screening mammograms. In Japan, as another example, ultrasound was already being used for breast imaging, so there just really wasn't a big focus on seeing how mimography would work there.

It was also evolving that breast cancer was a survivable and even curable disease if people caught it early, and this was feeding into that as well. Things moved a bit more slowly in other parts of the world. For example, in Europe in the nineteen seventies, only Sweden and Scotland conducted trials of screening mammograms. In Japan, as another example, ultrasound was already being used for breast imaging, so there just really wasn't a big focus on seeing how mimography would work there.

There were also doubts and controversies pretty much right away. Although the Hip study had shown a clear reduction in mortality. In the group that had regular breast exams. Only forty four cases of breast cancer had been found only through mimography over the course of that study. In many other cases, the patient's medical history, physical exam, or interview had already suggested the possibility of cancer.

There were also doubts and controversies pretty much right away. Although the Hip study had shown a clear reduction in mortality. In the group that had regular breast exams. Only forty four cases of breast cancer had been found only through mimography over the course of that study. In many other cases, the patient's medical history, physical exam, or interview had already suggested the possibility of cancer.

One of the people to publicly criticize the idea of screening mammograms was John C. Baylor, who was statistician with the National Cancer Institute. He published an article called Mimography A Contrary View and the Annals of Internal Medicine in January of nineteen seventy six. This is one of the moments where I was like, this was after I was born. His criticisms included the fact that many of the early cancers that were being diagnosed were very slow growing masses that might not ever reach a point where they were a risked to the patient's life. He also expressed concerns that the radiation exposure involved with a mammogram could contribute to breast cancers later in life. I'll pause to say the amount of radiation exposure is less now than it was in nineteen seventy six. He argued that the government should have been focusing its efforts on further randomized controlled trials, including trials specifically looking at the question of whether screening mammograms were worthwhile in patients under the age of fifty, and studies on more diverse groups of people, rather than a demonstration project like the BCDDP. Baylor initially criticized all screening mammograms, but eventually really focused his attention on the ones performed on women under the age of fifty.

One of the people to publicly criticize the idea of screening mammograms was John C. Baylor, who was statistician with the National Cancer Institute. He published an article called Mimography A Contrary View and the Annals of Internal Medicine in January of nineteen seventy six. This is one of the moments where I was like, this was after I was born. His criticisms included the fact that many of the early cancers that were being diagnosed were very slow growing masses that might not ever reach a point where they were a risked to the patient's life. He also expressed concerns that the radiation exposure involved with a mammogram could contribute to breast cancers later in life. I'll pause to say the amount of radiation exposure is less now than it was in nineteen seventy six. He argued that the government should have been focusing its efforts on further randomized controlled trials, including trials specifically looking at the question of whether screening mammograms were worthwhile in patients under the age of fifty, and studies on more diverse groups of people, rather than a demonstration project like the BCDDP. Baylor initially criticized all screening mammograms, but eventually really focused his attention on the ones performed on women under the age of fifty.

The same year that Baylor published this article, the American Cancer Society started recommending mimography for early breast cancer detection. We'll talk more about that after a sponsor break.

The same year that Baylor published this article, the American Cancer Society started recommending mimography for early breast cancer detection. We'll talk more about that after a sponsor break.

The American Cancer Society had started educational campaigns recommending that women examined their own breasts for signs of cancer in the nineteen thirties and forties. That, plus the increased use of screening mammograms in the late sixties and seventies, meant that more people were being diagnosed with breast cancer earlier than they might have been otherwise. But for decades, the standard treatment for breast cancer in the US and much of Europe had involved a radical mastectomy. This surgery was developed by William Stewart Halstead all the way back in eighteen eighty two, building on the work of earlier doctors. This included the removal of the breast and adjacent parts of the lymphatic system and the pectoralis major muscle.

The American Cancer Society had started educational campaigns recommending that women examined their own breasts for signs of cancer in the nineteen thirties and forties. That, plus the increased use of screening mammograms in the late sixties and seventies, meant that more people were being diagnosed with breast cancer earlier than they might have been otherwise. But for decades, the standard treatment for breast cancer in the US and much of Europe had involved a radical mastectomy. This surgery was developed by William Stewart Halstead all the way back in eighteen eighty two, building on the work of earlier doctors. This included the removal of the breast and adjacent parts of the lymphatic system and the pectoralis major muscle.

That's a major surgery. But when Halsta developed it, most breast cancers were detected when tumors were large enough to be obvious and had started to spread beyond the breast. But at least in theory, cancers that were discovered earlier might not need such a broad response. This led to questions of whether mammograms were going to lead to people having major surgery that they didn't actually need. So this ties into the history of breast cancer treatment, which of course could be a whole separate topic. The first chemotherapy drugs were developed in the nineteen forties and fifties. As we said, earlier experiments in radiotherapy as a cancer treatment had started almost immediately after the discovery.

That's a major surgery. But when Halsta developed it, most breast cancers were detected when tumors were large enough to be obvious and had started to spread beyond the breast. But at least in theory, cancers that were discovered earlier might not need such a broad response. This led to questions of whether mammograms were going to lead to people having major surgery that they didn't actually need. So this ties into the history of breast cancer treatment, which of course could be a whole separate topic. The first chemotherapy drugs were developed in the nineteen forties and fifties. As we said, earlier experiments in radiotherapy as a cancer treatment had started almost immediately after the discovery.

Of X rays. Surgeon John Madden modified Halsted's methods for the radical mastectomy in nineteen seventy two, with Madden's techniques preserving the pectoral missiles. Oncologist Umberto VERNESSI also promoted a more conservative surgery described as a quadrant ectomy, combining that with radiotherapy. Studies comparing the efficacy of radical mastectomies with Vernesi's methods started in Milan in nineteen seventy three, and this was part of a whole process of figuring out how to successfully treat breast cancers that were detected earlier without overtreating them, like, without giving people a more intense treatment than they actually needed.

Of X rays. Surgeon John Madden modified Halsted's methods for the radical mastectomy in nineteen seventy two, with Madden's techniques preserving the pectoral missiles. Oncologist Umberto VERNESSI also promoted a more conservative surgery described as a quadrant ectomy, combining that with radiotherapy. Studies comparing the efficacy of radical mastectomies with Vernesi's methods started in Milan in nineteen seventy three, and this was part of a whole process of figuring out how to successfully treat breast cancers that were detected earlier without overtreating them, like, without giving people a more intense treatment than they actually needed.

Complicating all of this was the fact that screening mammograms were identifying growths that were ambiguous. In other words, it wasn't obvious whether they were or were not cancerous. While the BCDDP was ongoing, a preliminary report suggested that sixty six of five hundred six pathological specimens collected so far had not actually contained any sign of cancer nor carcinoma in situ. Today, carcinoma in situ is sometimes called stage zero cancer, and it involves precancerous cells that have not spread, which may or may not become cancerous. Of those sixty six specimens that didn't have any evidence of cancerous or precancerous cells, fifty three had led the patient to undergo some type of mastectomy. The researcher stressed that the mammograms were not to blame for this, that other doctors had performed those biopsies, made those diagnoses, and recommended those surgical treatments. But all of this added to the ongoing questions about the idea of overtreatment.

Complicating all of this was the fact that screening mammograms were identifying growths that were ambiguous. In other words, it wasn't obvious whether they were or were not cancerous. While the BCDDP was ongoing, a preliminary report suggested that sixty six of five hundred six pathological specimens collected so far had not actually contained any sign of cancer nor carcinoma in situ. Today, carcinoma in situ is sometimes called stage zero cancer, and it involves precancerous cells that have not spread, which may or may not become cancerous. Of those sixty six specimens that didn't have any evidence of cancerous or precancerous cells, fifty three had led the patient to undergo some type of mastectomy. The researcher stressed that the mammograms were not to blame for this, that other doctors had performed those biopsies, made those diagnoses, and recommended those surgical treatments. But all of this added to the ongoing questions about the idea of overtreatment.

With all these kinds of questions in play and others, various states and the US federal government started working to regulate mammography. Between nineteen eighty six and nineteen ninety two, a number of laws were passed requiring things like dedicated mimmography machines at hospitals and inspections on those machines. The US passed the Mimography Quality Standards Act in nineteen ninety two, which was meant to help ensure the safety and efficacy of mimmography, including making sure the amount of radiation patients were exposed to was low. The American College of Radiology also developed the Breast Imaging and Reporting Data System or BIRADS in nineteen ninety three to provide standardized ways to describe and report mammogram results. Today, the byrad's AT list includes guidelines for multiple types of breast imaging, including mammography ultrasound and MRI.

With all these kinds of questions in play and others, various states and the US federal government started working to regulate mammography. Between nineteen eighty six and nineteen ninety two, a number of laws were passed requiring things like dedicated mimmography machines at hospitals and inspections on those machines. The US passed the Mimography Quality Standards Act in nineteen ninety two, which was meant to help ensure the safety and efficacy of mimmography, including making sure the amount of radiation patients were exposed to was low. The American College of Radiology also developed the Breast Imaging and Reporting Data System or BIRADS in nineteen ninety three to provide standardized ways to describe and report mammogram results. Today, the byrad's AT list includes guidelines for multiple types of breast imaging, including mammography ultrasound and MRI.

There were numerous advances in mimography technology and methods in the late nineteen eighties and nineteen nineties. Digital mimography was introduced in two thousand and one, and today most mammograms are digital, so radiologists can see the images instantly rather than waiting for films to be developed. Digital mimography also tends to be more accurate in people over the age of fifty, although the accuracy is about the same in people younger than that. Digital temosynthesis or three D digital mimography, was introduced in twenty eleven.

There were numerous advances in mimography technology and methods in the late nineteen eighties and nineteen nineties. Digital mimography was introduced in two thousand and one, and today most mammograms are digital, so radiologists can see the images instantly rather than waiting for films to be developed. Digital mimography also tends to be more accurate in people over the age of fifty, although the accuracy is about the same in people younger than that. Digital temosynthesis or three D digital mimography, was introduced in twenty eleven.

And there are other methods for breast imaging as well. Some examples include magnetic resonance imaging or MRI, ultrasound mimography with contrasts, which we mentioned earlier, positron emission mimography, and breast specific gammut imaging.

And there are other methods for breast imaging as well. Some examples include magnetic resonance imaging or MRI, ultrasound mimography with contrasts, which we mentioned earlier, positron emission mimography, and breast specific gammut imaging.

A lot of these.

A lot of these.

Today are used after a screening mammogram has revealed something that needs further evaluation, or after somebody has been diagnosed with breast cancer, to better visualize the tumor and to monitor progress during treatment.

Today are used after a screening mammogram has revealed something that needs further evaluation, or after somebody has been diagnosed with breast cancer, to better visualize the tumor and to monitor progress during treatment.

In more recent years, there have also been recommendations for mammography to be paired with automated whole breast ultrasound in people with dense breasts, and at this point it's usually recommended in addition to not instead of a mammogram. But there's also an overall higher false positive rate for breast ultrasounds, including automated whole breast ultrasound, than there is for mammograms. Some of the concerns about mimmography that were raised in the wake of the Hip study continue to be debated today. Like the Hip study had shown clear evidence that routine breast cancer screening could reduce the number of deaths from breast cancer in people over the age of fifty, but there wasn't clear evidence for women between the ages of forty and fifty. Screening mammograms really didn't seem to make much of a difference in this age group. If you're in that age bracket, which I am, and you've gotten a mammogram, you may have gotten results describing your breasts as dense. Basically, younger bread guests contain a lot more connective tissue and other structures that show up on a mammogram, and that can make it harder to spot small tumors, but older breasts usually have less connective tissue and more fat, so tumors stand out more on a mammogram. In general, breast cancer risk also increases with age, So what's the right age for a person to start having mammograms? Guidance on this has changed repeatedly since the years of the Hip study, including an incredibly controversial recommendation by the US Preventative Services Task Force in two thousand and nine. That recommendation was that women between the ages of forty and forty nine not be routinely screened. There is still so much debate about the age at which people should start getting mammograms and how often they should get them after that point, and there's often a lack of consensus among different organizations and governing bodies about what those recommendations should be. Recommendations for transgender and non binary people are even more scattered in contradictory and are based on just really limited data. I read through these and I found them very confusing. And this is for a community of people. Trans and non binary people already often having a really high bar to getting compassionate medical care at all, just making it more complicated and based on limited data A cynical way to look at this debate about when and how often people should get mammograms, especially in places like the United States where we don't have universal health care, is that this is all about money and what insurance companies are willing to pay for, especially when it comes to people under the age of fifty. There definitely are arguments about whether routine mammograms are the cost effective way to detect signs of breast cancer. I read some of those papers. I found them irritating. To the National Cancer Institute, more than seventy five percent of women in the US between the ages of fifty and seventy four have had a mammogram within the last two years, but more than half of breast cancers are discovered by the patients themselves or their partners, not from a mammogram. So that's like a question of like, wouldn't it be cheaper to just make sure everybody's getting regular physical exams.

In more recent years, there have also been recommendations for mammography to be paired with automated whole breast ultrasound in people with dense breasts, and at this point it's usually recommended in addition to not instead of a mammogram. But there's also an overall higher false positive rate for breast ultrasounds, including automated whole breast ultrasound, than there is for mammograms. Some of the concerns about mimmography that were raised in the wake of the Hip study continue to be debated today. Like the Hip study had shown clear evidence that routine breast cancer screening could reduce the number of deaths from breast cancer in people over the age of fifty, but there wasn't clear evidence for women between the ages of forty and fifty. Screening mammograms really didn't seem to make much of a difference in this age group. If you're in that age bracket, which I am, and you've gotten a mammogram, you may have gotten results describing your breasts as dense. Basically, younger bread guests contain a lot more connective tissue and other structures that show up on a mammogram, and that can make it harder to spot small tumors, but older breasts usually have less connective tissue and more fat, so tumors stand out more on a mammogram. In general, breast cancer risk also increases with age, So what's the right age for a person to start having mammograms? Guidance on this has changed repeatedly since the years of the Hip study, including an incredibly controversial recommendation by the US Preventative Services Task Force in two thousand and nine. That recommendation was that women between the ages of forty and forty nine not be routinely screened. There is still so much debate about the age at which people should start getting mammograms and how often they should get them after that point, and there's often a lack of consensus among different organizations and governing bodies about what those recommendations should be. Recommendations for transgender and non binary people are even more scattered in contradictory and are based on just really limited data. I read through these and I found them very confusing. And this is for a community of people. Trans and non binary people already often having a really high bar to getting compassionate medical care at all, just making it more complicated and based on limited data A cynical way to look at this debate about when and how often people should get mammograms, especially in places like the United States where we don't have universal health care, is that this is all about money and what insurance companies are willing to pay for, especially when it comes to people under the age of fifty. There definitely are arguments about whether routine mammograms are the cost effective way to detect signs of breast cancer. I read some of those papers. I found them irritating. To the National Cancer Institute, more than seventy five percent of women in the US between the ages of fifty and seventy four have had a mammogram within the last two years, but more than half of breast cancers are discovered by the patients themselves or their partners, not from a mammogram. So that's like a question of like, wouldn't it be cheaper to just make sure everybody's getting regular physical exams.

I find that I'm like, this is it cheaper? I find that to be a frustrating way to look at it.

I find that I'm like, this is it cheaper? I find that to be a frustrating way to look at it.

I have a question about that that we can table till an so frietay, sure, yes, But beyond all of that, there are real questions about the efficacy of mimography as a screening tool, especially in people under the age of fifty. As we said earlier, it's not just about the fact that a higher breast density can make small tumors harder to see. There are also questions around the risks of false positive and overtreatment. As we're result of earlier annual mammograms. It's estimated that over the course of ten screenings, roughly half of patients in the US will experience a false positive and roughly twenty percent of patients in Europe. And there are still lingering questions about overtreatment and whether very small growth seen on mammograms need to be treated or would ever jeopardize the patient's life in any way.

I have a question about that that we can table till an so frietay, sure, yes, But beyond all of that, there are real questions about the efficacy of mimography as a screening tool, especially in people under the age of fifty. As we said earlier, it's not just about the fact that a higher breast density can make small tumors harder to see. There are also questions around the risks of false positive and overtreatment. As we're result of earlier annual mammograms. It's estimated that over the course of ten screenings, roughly half of patients in the US will experience a false positive and roughly twenty percent of patients in Europe. And there are still lingering questions about overtreatment and whether very small growth seen on mammograms need to be treated or would ever jeopardize the patient's life in any way.

So we can't speak from experience about other parts of the world. Holly and I live in the United States, but here there are huge disparities and who has access to screening mammograms, including who has access to the newer technologies like three D mimography, and these disparities are often compounded in every step of the process. So a person who can't get an appointment, or can't get an appointment at a place that has the most up to date equipment or can't afford a mammogram at all, or feels unwelcome at the doctor due to factors like medical racism and fat phobia and trans phobia. They're gonna have these same exact issues again when it comes to follow ups if additional imaging is needed. Treatment can also be incredibly expensive for breast cancer, even in people who have insurance, and so all of this contributes to racial and economic disparities in breast cancer detection rates and survival rates for breast cancer, with black women in the US in particular being a lot just disproportionately more likely to die from the disease. I know that is a kind of dire place to leave off the episode.

So we can't speak from experience about other parts of the world. Holly and I live in the United States, but here there are huge disparities and who has access to screening mammograms, including who has access to the newer technologies like three D mimography, and these disparities are often compounded in every step of the process. So a person who can't get an appointment, or can't get an appointment at a place that has the most up to date equipment or can't afford a mammogram at all, or feels unwelcome at the doctor due to factors like medical racism and fat phobia and trans phobia. They're gonna have these same exact issues again when it comes to follow ups if additional imaging is needed. Treatment can also be incredibly expensive for breast cancer, even in people who have insurance, and so all of this contributes to racial and economic disparities in breast cancer detection rates and survival rates for breast cancer, with black women in the US in particular being a lot just disproportionately more likely to die from the disease. I know that is a kind of dire place to leave off the episode.

The Grim de new mal of the episode.

The Grim de new mal of the episode.

Yeah, I didn't feel like I could just leave that out.

Yeah, I didn't feel like I could just leave that out.

Do you have less Grim listener mail?

Do you have less Grim listener mail?

Do I have much less Grim listener mail? Fabuloush The clistener mail came from Dave and Dave's subject line is just Assassin's Creed origins. Dave wrote, Hi, Holly and Tracy, I guess I have a PhD in the show. Since I've been listening to the podcast from the very start, I've loved the many evolutions of the show over the years, and I'm grateful for all the hard work you put into it. Naturally, I've been tempted to write several times, especially since my hometown of Saint Catherine's, Ontario has appeared in a number of episodes, but I never felt I had something worth sharing, well, at least until you talked about Assassin's Creed. During the Banu Musa episode. You touched upon how ubsoft tries to add some level of historical accuracy to the backgrounds in the game. What you may not realize is that historians and museums have taken note of that. I volunteer at the Nilson Atkins Museum in Kansas City. It's a world class museum and I love giving tours and interacting with guests. Before the pandemic, we had an episode on Nefertari was an amazing collaboration with the museum, Egzo and for In Italy. Featured prominently in the exhibit were animated outtakes from an educational version of Assassin's Creed origins. You can find these online at Ubusov's website and there's a link to that. Needless to say, it was very cool to have these recreated sites next to actual artifacts, and people love it. So I hope you enjoy that tidbit and don't get stuck in the rabbit hole of these Assassin's Creed discovery tours. Here's my pet tax. What follows is an adorable black kitty cat asleep on a cream colored carpet. Cricket is a Manx. This breed typically do not have tails. She's got a lot of personality and wants a lot of attention. Although she refuses to be a lap cat. She wants her tribute on her terms. Keep up the great work, sincerely, Dave. I love this kitty cat.

Do I have much less Grim listener mail? Fabuloush The clistener mail came from Dave and Dave's subject line is just Assassin's Creed origins. Dave wrote, Hi, Holly and Tracy, I guess I have a PhD in the show. Since I've been listening to the podcast from the very start, I've loved the many evolutions of the show over the years, and I'm grateful for all the hard work you put into it. Naturally, I've been tempted to write several times, especially since my hometown of Saint Catherine's, Ontario has appeared in a number of episodes, but I never felt I had something worth sharing, well, at least until you talked about Assassin's Creed. During the Banu Musa episode. You touched upon how ubsoft tries to add some level of historical accuracy to the backgrounds in the game. What you may not realize is that historians and museums have taken note of that. I volunteer at the Nilson Atkins Museum in Kansas City. It's a world class museum and I love giving tours and interacting with guests. Before the pandemic, we had an episode on Nefertari was an amazing collaboration with the museum, Egzo and for In Italy. Featured prominently in the exhibit were animated outtakes from an educational version of Assassin's Creed origins. You can find these online at Ubusov's website and there's a link to that. Needless to say, it was very cool to have these recreated sites next to actual artifacts, and people love it. So I hope you enjoy that tidbit and don't get stuck in the rabbit hole of these Assassin's Creed discovery tours. Here's my pet tax. What follows is an adorable black kitty cat asleep on a cream colored carpet. Cricket is a Manx. This breed typically do not have tails. She's got a lot of personality and wants a lot of attention. Although she refuses to be a lap cat. She wants her tribute on her terms. Keep up the great work, sincerely, Dave. I love this kitty cat.

I used to have a Manx and I loved him desperately, and it was like living with a really fabulous drag queen.

I used to have a Manx and I loved him desperately, and it was like living with a really fabulous drag queen.

Oh.

Oh.

It would look you up and down and be like you're wearing that today? Like chess?

It would look you up and down and be like you're wearing that today? Like chess?

Yeah, the goofiest, sweetest but also slightly attitudinous. Yeah. So I knew that these discovery tours existed in the Assassin's Creed games. I have never actually checked any of them out on my games. I see them there in the menu, I see that there are achievements for doing them. I have not actually done any of them. I did not know though, that they were also used in museums and educational centers to like add another element to the educational stuff. I think that is pretty cool. So thanks so much for this email day. If you'd like to write to us, we're History podcast at iHeartRadio dot com. We are on social media at Missing History. That's where you'll find our Facebook Twitter. It's not even called Twitter anymore. I don't know why even say it is.

Yeah, the goofiest, sweetest but also slightly attitudinous. Yeah. So I knew that these discovery tours existed in the Assassin's Creed games. I have never actually checked any of them out on my games. I see them there in the menu, I see that there are achievements for doing them. I have not actually done any of them. I did not know though, that they were also used in museums and educational centers to like add another element to the educational stuff. I think that is pretty cool. So thanks so much for this email day. If you'd like to write to us, we're History podcast at iHeartRadio dot com. We are on social media at Missing History. That's where you'll find our Facebook Twitter. It's not even called Twitter anymore. I don't know why even say it is.

To me.

To me.

I think it's always Twitter in my heart.

I think it's always Twitter in my heart.

I refuse to acknowledge.

I refuse to acknowledge.

And you can subscribe to our show on the iHeartRadio app or wherever else you like to get your podcasts. Stuff you Missed in History Class is a production of iHeartRadio. For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.

And you can subscribe to our show on the iHeartRadio app or wherever else you like to get your podcasts. Stuff you Missed in History Class is a production of iHeartRadio. For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.