Breast Cancer Risk: Testing to Tailored Screening, Treatment, and Prevention

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Hubwonk podcast transcript, August 29, 2023


Joe Selvaggi: This is Hubwonk. I’m Joe Selvaggi

Welcome to Hubwonk, a podcast of Pioneer Institute, a think tank in Boston. Breast cancer is a scourge. Nearly a quarter million Americans are diagnosed and more than 40,000 patients die from the disease every year. The battle to combat breast cancer is now fought on three fronts. The science of early detection, the procedures to treat and cure.

And the testing of DNA to identify and help protect those with elevated risk, but as promising, as better screening and new technological breakthroughs are, they’re only effective if they’re widely understood and applied. For too many patients, the standard of care is designed for an average patient leaving those with elevated risk, unaware of the need for better screening, and more tailored therapies.

For instance, for those with dense press tissue, an MRI is more effective for early detection than the commonly used mammogram. For those with genetic [00:01:00] risk, A DNA test could indicate a benefit of prophylactic treatment that some estimate could prevent nearly 25% of new breast cancer occurrences. How can a healthcare system that prioritizes the average over the individual and treatment over prevention and detection better serve those patients with unique or elevated breast cancer vulnerabilities?

And what can patients do to better protect themselves by insisting on a testing regimen that addresses their particular personal risk profile? My guest today is Hannah Mamuszka, chief executive at Alva 10, and an expert in precision medicine, her research on the benefits of more precise testing and treatment suggests that for some women, many common screening tools are inadequate for early detection of cancer. Her work with DNA testing goes further to suggest that for some vulnerable patients, appropriate therapies before the onset of disease could serve to substantially reduce breast cancer cases. Her analysis suggests that with better-informed doctors and patients, along with improved incentives for testing,  patients could enjoy better breast cancer treatment at substantially lower costs.


Ms. Mamuszka will share with us how current incentives in our healthcare prioritize treatment over-testing, and how policymakers could help reorient patients and their doctors towards more individualized and effective care. When I return, I’ll be joined by Alva 10, chief Executive Anna Mamuszka.

Okay, we’re back. This is Hub Wonk. I’m Joe Silva and I’m now pleased to be joined by Chief Executive Officer of Alva 10 and friend of the podcast, Hannah Mamuszka. Welcome back to Hub Wonk Hannah. Thanks again for having me, Joe. Alright it’s a pleasure to have you, you’re a great guest. But what today we’re gonna be talking about breast cancer more specifically policy recommendations that could serve to better detect or perhaps even prevent the disease.

But before we get into that [00:03:00] particular topic, you’re an expert in precision medicine. For the benefit of our listeners, what is precision medicine?

Hannah Mamuszka: So precision medicine is this idea of going from treating everyone like they’re the average to really treating everyone based on the known mechanisms of their own personal disease.

So historically, before we had the ability to look at genes and proteins, we just would treat everyone as though they were basically the same and hope that the average benefited most people. And the good news is we don’t have to do that anymore. Now we can actually look at data and inform how patients are treated across disease areas based on their specific characteristics and really hopefully tailor treatment to the patient.

Joe Selvaggi: Indeed. Whereas medical professionals everybody walks through the door, they think standard of care is just, let’s give everybody the average treatment. We find that to be costly, inefficient, and potentially deadly for treating, everybody the same. We’re missing some of the special cases.

And the flip side of that is [00:04:00] precision medicine suggests that with proper screening and even down to the DNA level of course we’re gonna treat people differently based on age, sex, family history. All of that makes for a far more efficient both more cost-efficient, but also more effective treatment.

Is that fair to generalize?

Hannah Mamuszka: Absolutely. Estimates of waste in our healthcare system, by lack of using precise tools is about 40 to 45% of our total cost. So when you think about how much money we’re wasting in healthcare, because we’re not optimizing these tools, it is a tremendous economic cost.

And every one of those dollars really is a patient cost more than anything.

Joe Selvaggi: Indeed a system that’s more than $4 trillion deserves some attention for efficiency. And again I say this isn’t for all our knowledge, it really, knowledge is useless unless people know it. The last time we were on, we were talking about, can you believe covid and what’s the difference between A P C R and an antigen test?

It’s remarkable to me, to today, to Liz Day, people don’t understand which test is used for which purpose. The accuracy doesn’t seem to be [00:05:00] something that gets out there.

Hannah Mamuszka: Yeah, I think it’s a confusing space, and there are a lot of reasons why I think the diagnostics industry hasn’t been able to communicate more effectively.

And part of it is economics. Our healthcare system is really, spends a lot more money on the therapeutic side than the diagnostic side. And so there’s not a lot of direct-to-consumer commercials to inform patients on what diagnostics they should be asking for.

Joe Selvaggi: Indeed. So let’s focus then on our topic today.

Breast cancer. I’m sure our listeners will have some connection to a mom or a sister or a daughter, or, this is a terrible disease. Of course. Again, in my question, I’ve already made a generalization, assuming breast cancer affects. Women alone give us the real sense of how big is this disease, how many people are affected, and am I ignorant?

Do men get breast cancer? Or is that sort of not true?

Hannah Mamuszka:  Men do get breast cancer. They don’t get screened for breast cancer. It’s a relatively small percentage of the total breast cancer diagnoses per year. It’s, between one and 4%, depending on the statistics that you look at.


Breast cancer is the most significant cancer in women. It’s the top killer of women. And we have a lot of screening tools for breast cancer, but we’re not actually using them very well. And that’s troubling because the rates of breast cancer in some populations are increasing and we need to use better tools in order to prevent the mortality from increasing as well.

Joe Selvaggi:

Indeed, I was reading up on the case I read that 240,000 people are diagnosed with breast cancer every year, and about 42,500 people die every year. That’s number of people die in car crashes, and any of this is a huge disease. When you mentioned some populations, the incidents of breast cancer is going up.

Can you share with our listeners what are the trends as far as who’s getting it and, are we winning the battle or are we losing the number of people who are being diagnosed?

Hannah Mamuszka: We’ve definitely won some of battles because we are screening more women for breast cancer.

[00:07:00]But we’re seeing trends of younger diagnosis and some demographics, particularly in African-American women. We’re also seeing a connection between obesity, type two diabetes and increasing rates of breast cancer. And I don’t think we have done as good of a job at communicating the link between obesity and cancer as we have between smoking and cancer, but particularly in postmenopausal women.

Obesity in type two diabetes is a significant risk for breast cancer.

Joe Selvaggi: Okay. Obesity, we know is probably good for it’s a bad thing. For a lot of issues. We, again,, going back to covid we saw that to be a risk factor, a profound risk factor. What about I know that when I go and see the doctor, family history seems to be very important.

Among the first questions I’m asked how much does family history have to play with this?

Hannah Mamuszka: Family history and genetics. So knowing whether or not you are a carrier of the BRCA gene are really important to know your risk for breast cancer. But what most people don’t realize is that’s only about 15% of breast cancer cases.

So in other words, 85% of people who get breast [00:08:00] cancer have no known family history and no known genetic history of breast cancer.

Joe Selvaggi: Though you’re an advocate for testing and looking for markers that suggest a higher risk, you’re humble in saying 85% of those folks who get breast cancer have no.

Quote-unquote genetic predisposition, right?

Hannah Mamuszka:  They have no genetic predisposition, but there are other diagnostic tools that we can use. There are diagnostic tests called integrated risk assessments sometimes known as polygenic risk assessments, which have been a bit misunderstood historically, but there’s actually abundant data now suggesting that when you look at these integrated risk assessments, one of them is A test called gene type.

You can look at them and you can actually determine between a group of genes and your physical history, what your risk of breast cancer is. That is separate from your BRCA status, and that allows a woman or a patient to figure out how much additional screening [00:09:00] they might wanna do, or if they may wanna make lifestyle changes because now they understand that they are at an increased risk for breast cancer.

Joe Selvaggi: It’s a more holistic multifactor analysis. So some you can affect, you can’t affect you, you can’t choose your genes, but you can affect your lifestyle. What are some of I won’t call this a lifestyle choice, but choices, let’s say having children or other sort of life choices that will affect your overall profile and probability.

Hannah Mamuszka: Certainly having children is known to decrease risk of breast cancer. But the other thing that actually decreases risk of breast cancer even more is reducing alcohol intake. So alcohol is another established risk factor for breast cancer. So if you are at increased risk of breast cancer, or anyone should really consider that when they consider their alcohol consumption.

Joe Selvaggi: Okay, so drink less. And of course, you mentioned smoking. We already know that’s old news. Not worthy of our conversation but having children reduces and I think having children earlier rather than later. I read details relating to that.  Yes, that’s also true.


Okay. Alright. So let’s say, okay, we have these screening tools that we can a woman will walk in we will look at her DNA perhaps but we’ll also look at holistically what other risks she may have. But unfortunately, I think most people will discover they have. Breast cancer by doing a self-test, perhaps detecting a lump in the breast.

Can you say more about, let’s say what is standard care? What should women be looking for when looking for cancer?

Hannah Mamuszka: Sure. There are really two screening modalities that we have that are in theory available to every woman, or at least every woman over 40. One of them is doing a breast self-exam, which women are taught to do starting in high school in the United States.

And then the other is mammography. Breast self-exams are great, but they actually, you’re actually not able to feel a type of breast cancer called invasive breast cancer. It doesn’t present with a lump. In the way that you think of hearing about, you felt a lump that felt like a hard p or something like that, invasive breast cancer, you can’t digitally feel with your [00:11:00] fingers.

You need to see it on imaging. So while every woman should be aware of how to do a breast self-exam it’s not gonna find every type of breast cancer. And there is an a slightly increased rate of detection in the past 10 years. In invasive breast cancer. The other tool we have is mammography and some mammograms are now recommended for every woman over 40.

It used to be 45 and now it’s 40. Unless you have genetic history in which we, you would start earlier.

Joe Selvaggi: For the lay people in our audience and those who have not been through a mam mammogram, it’s effectively an x-ray of the breast.

Hannah Mamuszka: It is effectively an x-ray of the breast. It takes a picture. It’s not super comfortable, but it doesn’t take very long.

It’s pretty cheap to do. And it is covered under the Affordable Care Act as required screening.

Joe Selvaggi: Now I don’t want to ask this question. It’s too clumsy as a man, but does the size of breasts or the I’ve heard something about called dense breasts, does that matter, size and density, does that have an effect on either the probability of having cancer or [00:12:00] the detectability of that cancer?

Hannah Mamuszka: That is a really common misconception, and I think we all need to talk a little bit more about breasts than we do because neither size nor how you, how your breasts physically feel you can elucidate whether or not you have dense breasts. Dense breasts is a description that you can only tell by imaging.

You can’t tell by feel. Women with larger breasts are only at a higher risk. For breast cancer just because they have more breast tissue. But it’s really the density of the breast, which can only be seen on imaging, which also can potentially increase the person’s chance for cancer.

Joe Selvaggi: So is that an actual medical, I don’t know if you call it diagnosis or description. There is a, discrete term called dense where one side is not dense and the other side is dense. Yeah.

Hannah Mamuszka: There’s actually a scale that goes A, B, C, D a scale of breast density. So if you have A breasts that means you have fatty tissue breasts that are not dense at all, and then through B C’s, heterogeneously dense [00:13:00] breasts.

And then D is very dense breasts and it’s really important, and it’s actually now required as a February 2023 for hospitals, radiologists, physicians to notify women when they have a mammogram. And the radiologist determines that they have dense breasts and they have to be notified. Now you have to be notified of your breast density because if you have dense breasts, a mammogram is useless.

Joe Selvaggi: So although, so we said it’s practically an x-ray of your breast. If I, if my x-ray can, look inside my brain or, look for all kinds of things, how could it not penetrate breasts regardless of density?

Hannah Mamuszka: It’s really about how it just obfuscates the x-ray. It’s if you look up in the sky and you see an airplane on a clear day, and then you look up in the sky and you can hear the airplane, but it’s behind clouds and you’re not really sure where it is.

That’s really the, that’s really what radiologists see. Radiologists see just this cloudiness on the scan, and it’s nearly impossible, particularly with really dense [00:14:00] breasts to be able to tell what is just normal, dense breast tissue versus what could be cancer, and the F d A Put out this guidance or put out this requirement in February of this year that everyone has to be notified by, I think the middle of next year on their breast density because they realize that, doing a mammogram on women with dense breasts isn’t actually giving them any information.

I don’t wanna say that it’s useless, but if you’ve seen. Films. If you’ve seen pictures, and you can find this online and I’ll put it up on our website the comparison of the two, you can’t possibly be confident that you’ve detected cancer or not.

Joe Selvaggi: So you get a diagnosis that you say is now mandated that you have dense breasts.

But you, what are you supposed to do? That information? You’re just supposed to say, stop going to get mammograms, because if you do, they’re functionally, oh, again, we won’t use the word useless, but far less useful or what are you supposed to do with that information?

Hannah Mamuszka: So ideally a physician would reach out to the patient and say, you have dense breasts, you should go for [00:15:00] supplemental screening.

So for the most part, the next stage of supplemental screening would be going to get a breast MRI. But here’s where the challenge is and here’s where, I hope the Massachusetts legislature is listening because in Massachusetts there’s no, in, in some states, there is a requirement for women with a diagnosis of dense breasts to have their breast MRI covered by insurance.

And we don’t have that in Massachusetts. So it’s really plan by plan. It’s state-by-state right now. It is not required under the Affordable Care Act or any, insurance mandate. And so it’s really a question that physicians and patients have to ask of insurance companies is, are you gonna cover this breast, MRI, which could be, a couple thousand dollars for this woman who’s had a mammogram and we have no idea if she has breast cancer or not, because we can’t see through the dense breasts.

Joe Selvaggi: Yeah for, forgive me for just stating what seems to be obvious here. We’re in a sense leaving those with dense breaths, unscreened presumably we saved some money by not [00:16:00] doing some MRIs that. Should be recommended. But ultimately everyone pays of course, with further treatment when someone does eventually get much more advanced diagnosis and of course the risk of mortality, those people may die.

So we’re really this is Pennywise and Dollar Ex I forget the phrase, but. We’re not spending our money,

Hannah Mamuszka: Then we’re not spending our money. And we’re also, I think we’re not really informing women that we’re leaving them unscreened, I’ve now had three friends or connections to my circle of women who had an MRI got told it was fine and clean, and then within six months we’re diagnosed with breast cancer and then we’re notified.

Oh, by the way, yeah. You have dense breasts. Wait a minute. Why? Why weren’t you notified earlier? Why weren’t you told you have dense breast? You should go get MRI supplemental screening to be able to figure out. What is actually going on within your breasts?

Joe Selvaggi: And that’s, I think you meant to say, I think you meant to say they, they had a mammogram and then later on with the

Hannah Mamuszka: Yes, [00:17:00] they had a mammogram and then within six months they got a diagnosis of breast cancer.

That was a shock to them because they didn’t think breast cancer grow that quickly. And it probably didn’t. It was probably there, but unable to be seen through the dense breast. MRI dense breast mammogram.

Mammogram, you’re gonna have to edit me here, Joe.

Joe Selvaggi: That’s okay. No, I think our listeners can follow along.

So we’re essentially saying, look prevention is where we wanna be detection. And one method works. And the other doesn’t in the case of dense breast. If you are diagnosed with dense breasts, which is mandated please then do the supplemental MRI. Okay let’s move on from detection to, you’ve got you’ve found a mass, you’ve found some sort of I irregular abnormality, and you worry that you may have breast cancer.

What comes next?

Hannah Mamuszka: What comes next would via a breast biopsy where they will take a small sample, usually through a needle biopsy, and they’ll also place what’s called a little clip, which no one likes. But they put a little, tiny little clip [00:18:00] in the place where they took the biopsies so that they can monitor that area.

And so when they take that tissue, they can assess the tissue, they can see if it’s normal, they can see how the cells look, how they can see how they’re dividing even if they’re normal. Sometimes you can have normal cells that are a little on the abnormal side that you wanna keep a watch on, and that’s why they put that little clip in there so that the next time you have a mammogram or an MRI, they know the exact space that they went into biopsy before.

And they can take a look at, a closer look at those cells. And then when you get the biopsy, you can find out if it’s cancer and what type of cancer. So

Joe Selvaggi: You anticipate my next question, I guess some if it’s not cancer, that means it’s some sort of benign mass, and we move on and say thank goodness if it is cancer.

Are there many different types of cancer from let’s say, slow-growing to, really bad cancer? How, what would be the diagnosis?

Hannah Mamuszka: There are a lot of different types of breast cancer. Breast cancer is one of the diseases where we have really advanced this concept of precision medicine [00:19:00] and looking at all of these different types of biomarkers within the tumor to inform how a patient should be treated.

And this type of information can include if the tumor is driven by hormones or if it’s not driven by hormones. Meaning should you take. A type of therapy that has hormone stimulation in it, not have hormones in it. Should you go on chemotherapy? Do you need radiation therapy? Do you only need surgery?

How aggressive do you need to be? Historically, 20, 30 years ago we used to treat. All breast cancer very aggressively with a lot of drugs, with a lot of chemotherapy patients would be really sick for a long time. And as we’ve developed data in this space, we’ve realized that not all breast cancer is the same.

Some breast cancer can be surgically excised and you don’t need to do anything else. And some breast cancer can be surgically excised and you need a little bit of therapy and some women need, much more aggressive therapy. Additionally, now Clinical guidelines recommend that if you are [00:20:00] diagnosed with breast cancer, you should be tested for presence of genetic mutations.

Just because you didn’t know whether or not you had BRCA or genetic family history previously with a breast cancer diagnosis, it’s now recommended that everyone be tested for those genes since we know that sometimes they’re present in patients that we didn’t anticipate.

Joe Selvaggi: I wanna tie some concepts we already covered, which is some cancer is caused by genetic predisposition.

What you could do with that information now that you’ve already have cancer and it’s it is more than an academic concern, right? You would say, okay, mine is this sort of genetics type, which would imply that I am going to get on the phone and talk to all my. Female relatives and say, by the way, though, you have not been tested.

I have. And our mine is the kind that one inherits and therefore, Increases everyone in our family’s risk of cancer. Is that fair?

Hannah Mamuszka:  That’s fair. Male relatives too. Because there are certain types of BRCA mutations that can inform [00:21:00] on cancers that are more prevalent in men like pancreatic cancer. And also sometimes men can be carriers and people don’t realize that the family gene is actually being passed through through the male. So it’s important to, it’s important to notify everyone, but also knowledge of genetic status does inform treatment. So it informs how that patient could be treated what drugs, they may be likely to respond to, and also how aggressively they should be treated.

Joe Selvaggi: I’ve heard terms of course of cancer for all cancers is these stages 1, 2, 3, and four.

Briefly, you don’t have to get too deep, but what does each level mean? I don’t think there’s five. Five is, that’s bad. So what do they mean?

Hannah Mamuszka: You can think of stages one through four as how close it is to the primary site. So stage one breast, stage one, or stage zero breast cancer is very closely located to where the cancer started.

It means it hasn’t spread, it hasn’t, spread to the lymph nodes. It hasn’t spread to organs Cancer, breast cancer on its own, [00:22:00] simply contained in the breast is not going to kill you. It’s not gonna hurt you. Breast cancer that lives in the breast can stay there forever. The problem is that.

Generally doesn’t stay there. It usually moves. And when it moves to an organ that your body needs to live, that’s really where you get into trouble. And so stage one is locally confined. Stage two, you may have, you would have lymph node involvement. Stage three and stage four start to get into the organ involvement where you may have breast cancer found in your liver and your pancreas, and your lungs and your spine, and your brain.

That’s really where it becomes a systemic disease where you can’t treat it locally. And you need to treat it with more aggressive agents. And, the survival really drops off in terms of time when you get into later-stage breast cancer, which is why it’s so critical for women to know what their risk is, know what their screening options are, find the cancer as early as possible and get treated for it.

Joe Selvaggi:

[00:23:00] Indeed. Again, if  we take away nothing from this conversation, it’s the earlier you get it the earlier you’re detected, the better you are. I wanna bring up just one concept. The idea of a mastectomy. I hear these horrible stories about mastectomies. When does that come into? Is that a function of how far along the cancer is or what type of cancer?

Or, why would someone get a mastectomy versus someone who would not be recommended to have one?

Hannah Mamuszka: It’s really a function of what type of cancer it is. If a cancer is progressed, if you have stage three or stage four breast cancer, it’s already to the point where it’s spread, be beyond the breast.

That wouldn’t be the deciding factor on getting a mastectomy, but how aggressive the cancer is, whether or not you have genetic family traits. How quickly the cells are growing and the sort of the genetics behind the cells. We have a lot of data now that tells us which biomarkers suggest that cancers grow more quickly or more slowly.

That really informs how a physician would recommend a mastectomy or not to patients. It used to be. Back [00:24:00] 20 or 30 years ago, we recommended mastectomy much more frequently because we didn’t understand how to tell the difference between breast cancers that grew quickly and were more dangerous versus breast cancers that grew more slowly or were more indolent, and now we really have, 30 years of information to help a woman make that decision.

Joe Selvaggi: Okay, so now we’ve we’ve gone through all the stages here. Now, we’ve either surgically excised the lump or treated the patient and they are, quote-unquote, cancer free. What do we know about, let’s say, after someone’s been treated? And I don’t know if you ever cured or you clear that up for us, but what are the risks post-treatment, and, what should our listeners know about that?

Hannah Mamuszka: So there are some diagnostic tests that can be used post-treatment to monitor risk of recurrence. And this, some patients are gonna give, be given the option after they have their surgery and their initial treatment to either continue with chemotherapy or continue with hormone therapy depending on the biomarkers of their cancer.

And there are diagnostic tests like Genomic Health [00:25:00] Oncotype dx, for example, which tells a woman if they are at high risk of recurrence in the next five years, and if they’re at high risk of recurrence, they may want to make the decision to stay on chemotherapy for longer to try to prevent that recurrence from happening versus not continuing a therapy because they’re at such low risk, it’s unnecessary.

Similarly, Hologic has a test called Breast Cancer Index, which tells a woman if she should stay on hormone therapy for five or 10 years. Historically, it was thought that hormone therapy was not that big of a deal and that every woman should just go on hormone therapy to keep their cancer at bay.

But really, data shows that, most women don’t need to be on hormone therapy for an extended period of time, and the side effects from hormone therapy can be pretty horrific from neuropathic pain that makes your hands unable to be used, to significant depression, sexual dysfunction. And so it’s important for women to know that there are diagnostic tools out there that can help them decide [00:26:00] if they need to and want to stay on these therapies long term based on their risk.

Joe Selvaggi: Okay we’ve talked, this show has been really about the value of testing and precision medicine is effective in saving money in that we’re not treating the wrong people with the wrong procedures. But lemme please devil’s advocate and put on my my hat of there’s lots of ways to waste money.

One, of course, as we’ve covered is using medicine for the wrong disease for the wrong person. The other is overutilization. That’s a fancy word for saying we’re you we’re spending a lot of money on things that don’t really have much value or we’re doing tests that may have false positives in which case we’re having otherwise healthy people go through all kinds of expensive procedures that would not have been Needed had they not been tested as thoroughly.

So I’m gonna just play devil’s advocate and say what’s the risk of here of having too much testing and turning up too many false positives.

Hannah Mamuszka: Yeah. That’s always a risk. And I think if we start in the beginning of breast cancer, like if we start [00:27:00] on the risk stratification and diagnosis side, how do we think about triaging breast?

MRI, we could triage breast, MRI. For women with dense breasts by using a integrated risk assessment score and say, okay, you have dense breasts and you have, a high polygenic risk of having breast cancer. So you should have a breast MRI on an annual basis versus. Maybe someone else who has a very low chance of breast cancer and they would have a breast MRI on a biannual basis.

You could certainly stratify it like that. I think also we could reconsider the use of annual MRI in women with known dense breasts since it’s not just the cost of the mammogram, but it’s the entire cost of everything that goes into the mammogram appointment and the scheduling and the facility.

[00:28:00] If 40% of women have dense breasts and are not benefiting from mammogram, we should find another way to screen them that doesn’t produce either false positives or false confidence that they’ve been screened for breast cancer.

Joe Selvaggi: Indeed. You made a, before we started recording when we were communicating by email, you made a claim and I’ll let you fill in the blanks here.

With better testing, we could prevent, not just detect, prevent 25% of breast cancer from even happening. I found that so provocative that I wanted to roll up my sleeves and go deep into this. Can we prevent 25% of these, quarter million diagnosis share with our listeners?

Hannah Mamuszka:  Yeah, that’s not my statistic.

So it’s, I actually hadn’t realized this. So I’ve spent almost 30 years in cancer research and diagnostics. But it wasn’t until the past couple years that I’d gone back to guidelines that have existed for 20 years and realized that in current clinical guidelines, there is recommendation for the use of what’s called risk-reducing medication.

So it is for the use of low levels of hormone therapy in certain women who have an elevated risk of breast cancer. And if we actually identified [00:29:00] women who are at elevated risk for breast cancer and they were informed and recommended to start risk-reducing medication, that is the statistic that has been calculated of the percent of women where we would prevent breast cancer from ever occurring.

And what really makes me mad is most women don’t even know that risk-reducing medication is even an option. And I’ve asked some experts in the breast space, why did we used to do this? Because we used to do this, in our healthcare system, we used to recommend this medication much more frequently.

And what I was told is when the medication was patented and brand name. It was, it had a whole sales force behind it. And, there was the pharma support and now the medication is generic and there’s no support for it. And the use of risk-reducing medication has dropped off dramatically to the point where most women who, even women who know they’re at an elevated risk for breast cancer, are not given the [00:30:00] option.

And it is a very thought-provoking statistic. Certainly, not every woman who is known to be at elevated risk for breast cancer would choose risk-reducing medication for sure. But I think every woman deserves the knowledge and deserves the opportunity to make that decision themselves.

Joe Selvaggi:

Indeed. That’s a lot to contemplate. Those of us who love markets. Clearly, this is a market failure. There’s no incentive other than a woman’s incentive to live to prescribe this. There’s no financial incentive, I should say. That, that’s a moment for pause. So again, this is a great segue.

We’re getting to close to the end of our time together. I’d like to do the king, or as it were, queen for a day question. I’m gonna give you the chance to have what you would recommend patients all do, what you would recommend policymakers or perhaps the insurance and medical community do differently with this knowledge that we, you and I have discussed today.

Hannah Mamuszka: Yeah, thanks Joe. The one point I really want everyone to hear is that 85% of women who get breast cancer have no known family history or genetic risk. And so we need to [00:31:00] have better tools for women to be able to understand their risk and get better screening based on that. The fact that Massachusetts currently has no requirement, we have a requirement and we’ve had the requirement actually longer than the federal requirement for notification of women with dense breast a after mammogram, but no supplemental screening requirement, I think is a massive failure of our healthcare system. We need to have a way for women who get notified that they have dense breasts to be able to do the appropriate screening for their biology and for their level of risk.

And I would say to women out there who are listening, don’t be afraid to ask for a BRCA test to ask for a integrated risk assessment. A test like gene type, a polygenic risk test so that you can have a better understanding of what your breast cancer risk is, and decide how aggressively you wanna pursue supplemental screening for yourself.

Joe Selvaggi: Wow, that’s those are great points.[00:32:00] I always at the end of every show in my closing afterward, as I recommend we share ha blanc with friends I’m gonna make a shameless plug to have this particular show be extra shared because anyone listening has somebody in their universe who could benefit from this insight, this information.

If you share no other episode, please share this one with friends that you know, that could benefit from this recommendation. That’s all the time we have today together. Hannah, I really appreciate you coming on the show and sharing with us. Hopefully, who knows? I hope we’ve at least Saved or extended or helped people with their lives from the information you’ve offered.

Thank you very much, Hannah.

Hannah Mamuszka: Thank you so much, Joe.

Joe Selvaggi: This has been another episode of Hubwonk . If you enjoyed today’s show, there are several ways to support Hubwonk and Pioneer Institute. It would be easier for you and better for us. If you subscribe to Hub Wonk on your iTunes podcatcher, it would help others find Hubwonk if you offer a five-star rating or a favorable review.

We’re always grateful if you share Hub wonk with friends. If you have ideas or [00:33:00] suggestions or comments for me about future episode topics, you’re welcome to email me at Please join me next week for a new episode of Hubwonk.

Joe Selvaggi talks with precision medicine expert, Alva 10 CEO Hannah Mamuszka about how individualized testing can both detect and substantially reduce the incidence of breast cancer, a disease that accounts for more than 40k deaths each year.


Hannah Mamuszka is Founder & CEO of ALVA10, a healthcare technology firm. Hannah has spent her 20+ year career in diagnostics – both in pharma and at diagnostics companies, in the lab and on the business side. She believes that the challenges of diagnostic technology fully impacting patient care are more commercial than technical, and conceived of ALVA10 to create a mechanism to pull technology into healthcare by aligning incentives through data. She regularly speaks on issues regarding advancement of technology in healthcare, is on the Board of Directors for two diagnostic companies and writes a column on the value of diagnostics for the Journal of Precision Medicine.