Ep. 135: Breast Imaging and Detection, It’s Not What You Think It Is with Dr. Robert Sheeler, MD
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We’re talking with former Mayo Clinic Medical Editor Dr. Robert Sheeler on more breast imaging issues and how functional and integrative medicine as well as some conventional medicine practices can be evaluated in learning about your options. Breast imaging and detection isn’t a one size fits all conversation. Learn what sources are available, how to interpret and understand all the different ones and what criteria to use to discover what is best for you.
LINKS AND RESOURCES:
Connect with and learn more from Dr. Robert Sheeler
Read Robyn’s Blog Post on The 6 Things to Know about Breast Cancer
Robyn: Hey there, my friend. This is Robyn Openshaw. I am the host of The Vibe show. And we just found out recently that a year and a half ago when we changed the name of this show to Vibe from its original title, which is Your High Vibration Life, that it never got changed in iTunes. And so I’ve been talking about this as the Vibe show, but a former employee of mine who has no longer been with us for that last year and a half. never changed it over. So I sure hope we didn’t lose people and it explains some things about what happened, but we are now current in all the places that you listen to the podcast as Vibe is the name of the show. And so if you’ve been confused or if there are two of the show in your apps, I would just go with the one called Vibe that has the most episodes in it.
So today we’re continuing on this path of learning about breast imaging. I’m going to go a bit deeper. We’ve already talked to some experts about this particular subject, but I’m going to go a bit deeper with Dr. Robert Sheeler. He’s a medical doctor out of the Mayo Clinic and for a very long time he was medical editor at the Mayo Clinic as the editor of the health letter. I really liked talking to him in advance of inviting him to be on the show because he takes such a neutral tone towards all things Western Medicine and what I call Standard of Care Medicine and all things Functional Medicine.
And I can imagine if he were your physician that he would just honor your wishes. He’s that kind of a doctor. He’s a family physician and he also has a specialty in treating headache disorders and he’s boarded and certified in Family Medicine, Functional Medicine, Integrative Medicine, Urgent Care, and with a Headache subspecialist. So he’s got, what is that, four or five different board certifications, which is pretty great. He also has a specialty in Neurologic disorders. He was an associate professor now emeritus at the Mayo Clinic and he and his wife run a clinic in Scottsdale, Arizona.
I think you’re going to enjoy hearing from him because he definitely leans towards Functional and Integrative Medicine, but he understands Standard of Care protocols and why they are sometimes used very well. And so you’ll probably find him to be straddling the middle of the road more than the people we usually have on the show.
So Welcome to the Vibe show Dr. Robert Sheeler.
Dr. Sheeler: Hello. Thank you for having me.
Robyn: Well, it’s a delight. I enjoyed our phone conversation where we kind of talked through your stance on different positions and we’re wanting to dig a little deeper when it comes to this very hot subject, very controversial subject of breast imaging, breast cancer. But I’d like to start with how you went from being fully western medicine standard of care medicine to you now kind of straddle a line, is a lot of the reason why I wanted to talk to you as you kind of offer both worlds. How’d you get into Functional Medicine and why?
Dr. Sheeler: Well, I’ve always been drawn to sort of leading edge things and whole person things. So I teach Tai Chi and Qi-Gong for many years. I’ve studied hypnosis and my wife did Andrew Weil’s program in Integrative Medicine. And while I was doing that, she said, well you should do something else too. And I said, well I’ve just certified as a headache subspecialist, doesn’t that count? She goes, no, you’re doing all this other stuff anyway. So why don’t you go do Functional Medicine while I do Integrative Medicine. So I did. And I fell in love with it because I really like the concept of looking for the biochemical root cause. They teach you that in medical school and then it’s lost into the world of, a person has this much blood pressure, give them this drug. If that doesn’t work, give them that drug, it’s lost in just the whole reflex from diagnosis labeling to treatment without as much time and energy looking into root causes.
And so I found that, sort of like I found my way back home in medicine. And then I also did the certification in integrative medicine because I’ve been doing so much of that kind of stuff along the way. But I really believe that good functional medicine, good integrative medicine is built on a base of scientific understanding. And I work with the Institute for functional medicine a bit. And they believe that as well, is that functional medicine rests upon a base of scientific understanding of physiology and biochemistry and all of those types of things. And that we just understand which pathways we’re modifying and we try to modify the more upstream rather than turn off part of your immune system downstream. We’d rather find out what’s stimulating your immune system abnormally upstream.
So that’s kind of how I got into that. And I really do believe I’m pretty much agnostic. So when we talk about breast imaging, when we talk about treatment for high blood pressure, when we talk about anything. Somebody goes, “oh, it has to all be natural. Or, Oh, that natural stuff is bad. You shouldn’t do that.” I’ve come to be pretty agnostic to which one it is. For 10 years before I left Mayo Clinic, I ran the neuropsychiatric medicine group and I bought $1 billion of Neuro and psychiatric drugs with my colleagues in neurology and psychiatry and I developed sort of an algorithm for assessing things. And this works for tests, it works for treatments, whether they’re acupuncture or an herb or a drug. And that algorithm is safety, effectiveness, cost effectiveness, availability and reimbursement.
And so if it’s not safe, then I don’t really want to be using it. If it’s not effective, then there’s no reason to spend your time or energy or money on it. And then is it cost effective? I mean, if it’s a drug that’s $5 million, that will make you live two days longer if you have colon cancer. Most people would say, I think I’d rather have my kids get that money then live two days longer and take a complicated drug. And then is it available? Because if it’s just one guy doing acupuncture on the north slope of a mountain in northern Japan then most people aren’t going to be able to get there.
And then the last part is, is it reimbursed? Because I think financial health is part of overall health, and so whether it’s an imaging test or a procedure or a an herb or a drug, I like to apply all those criteria rather than saying I’m for one thing or against another thing. I’m stepping back a little from the circle and just looking at things and trying to decide, okay, based on what we have, what makes the most sense for each person, and then I try to weave that into what’s their personal philosophy because you should figure out what the person and what their family and what their culture finds most acceptable rather than just say, we do this for everybody.
Robyn: Okay. I want to follow up on two of the things that you’ve said that I’d like a little more clarification on. First of all, I’m going to ask you what’s the difference between Functional Medicine and Integrative Medicine? I think our audience will be interested in that. And I’ll bring you back to this too, but I want to talk about the, is it reimbursed thing? Because I want to know if that rules things out if it’s not reimbursed, because that would rule out a lot of things in functional medicine, right? So I’d love for you to say more about that. But let’s start with Functional Medicine and Integrative Medicine. How are those defined? You said your wife went to Integrative Medicine. She said you should do Functional Medicine and then you ended up doing both, right?
Dr. Sheeler: Right. And she ended up doing both too because I told her Functional Medicine is so good that she had to do it. So our practice is Functional and Integrated Medicine combined with whatever else fits with the person’s philosophy. So Functional Medicine is more deep biochemistry and it looks at a lot of biochemical and physiologic processes and pathways. It looks more for optimal health in terms of, you know, when we say, oh well your lab tests are normal. Well normal in a population of people who are mostly not exercising, eating unhealthy diets and ultrahigh stress is maybe not where you want to set what is optimal just because it’s statistically normal in a population that’s not healthy.
So Functional Medicine looks at these biochemical pathways, it looks at herbs and supplements and drugs and devices and everything that modifies those pathways upstream to try and get better outcomes by finding the root cause. So I’d say Functional Medicine is deep biochemistry, root cause medicine, but it still has a very intense interpersonal component. So we use a tool called The Matrix and there’s an electronic version of that called The Living Matrix that takes a couple hours to fill out and it assimilates things in a systems biology approach.
So rather than saying, this is a cardiology problem, this is a pulmonology problem, this is an endocrinology problem, this is a problem with your Mitochondria, this is a problem with your signaling system or whether it’s neurotransmitters or hormones. So it looks at a lot of those kinds of things that cut across organ systems in our kind of siloed medical system where every group of doctors owns an organ and whatever happens to the rest of you outside of that organ, they might care about you as a person, but that’s where they live in that one organ system. Functional Medicine cuts across that in a biochemical, physiologic way.
Integrative Medicine on the other hand, it looks a lot at different traditions. It looks a lot at the interpersonal interactions. It looks at Ayurvedic Medicine and traditional Chinese medicine and herbal therapies and it tries to combine all of those into a very personalized approach. But it’s not as focused on the why and the root cause unless you go into the root cause of, you know, the psychodynamics and the interpersonal things.
A lot of times one of my patients comes in and says, “well I got a cold or I’ve got a sinus infection and you know, the reflex is, okay, great, well we can treat you in five minutes with an antibiotic and then you’re good. But my deeper reflex is, well, why did you get that sinus infection? Where you worn down? Have you not been sleeping? Are you stressed? Are you traveling too much? Is there something out of balance in your life? And so integrative medicine, will take it to that next level. Sometimes it will take it to very deep psychological levels. And functional medicine can go there as well but it’s more likely to take it to deep Biochemical immunology, physiology levels.
Robyn: Interesting. Okay. So back to the other thing that I wanted to follow up on. What about reimbursement? Are you seeing any trend for insurance companies to reimburse things inside Functional Medicine that used to be sort of scorned by the regular Standard of Care Docs? That would rule out a lot of things for a lot of people, a lot of things in functional medicine.
Dr. Sheeler: Right. So reimbursement is just one of the things on my discussion radar. And so some people don’t have very much resource and so if it’s not reimbursed, they can’t do it. And so we need to look at other pathways. So we do find that a number of the sophisticated functional medicine labs will bill insurance and sometimes they’ll get coverage and sometimes they won’t. And if they get good coverage then you get a better deal. And if they don’t then you end up paying more of it. And so reimbursement is just one thing on my radar map. And I try to fit that in with the person. If they have five homes, one in California and one in France and one in Miami and one in South America then they’re probably less concerned about is this test reimbursed.
But if you have somebody who is struggling and they’re really trying to find the cause of their illness, then we likely go more step wise and we try to get as much information as we can out of the types of things that are reimbursed. So a lot of times I like to use Functional Medicine or optimal range interpretations of normal laboratory tests and squeeze as much information out of them as I can as well as deep history as well as sort of targeting things. It’s like, oh well you got sick after you moved to an industrial city and you were living right next to the chemical plant. Well let’s figure out what kind of chemicals that factory had. Oh, it had cadmium and lead. Well let’s spend your money then on testing you for heavy metals rather than just a broader approach of testing everything.
So we like to do things in sequence. There are sort of three groups of people that use functional medicine. The very rich because they just want whatever’s leading edge and they go, hmm, this looks pretty good. The very intelligent because they often will study a lot and they’re trying to optimize their health and they read and study and try to understand. And the kinds of folks they often end up talking to after the regular doctors go, yeah, we don’t do that. That’s not how we do that and those aren’t the things we have access to. Then they end up doing that.
And then the very sick, so people who’ve been through everything else and stuff didn’t work for them. Then they say, well, I don’t really have the resources to do this, but I’m going to invest what resources I do have. Because let’s say you’re starting to get Alzheimer’s disease or let’s say somebody tells you your cardiac disease is not reversible and you think, I want to see what else is out there. That’s the third group of people that uses Functional Medicine and they tend to use it until they get better and then they go back to spending their resources on other things.
And so reimbursement just comes into it because even if you have five houses around the world, you might care about how things cost because a lot of people who have five houses care about that because that’s how they got to have five houses is by caring about how much things cost. And so I always just put that on the table so that people can factor that in as part of their decision. And that’s more for them to have data on all of those realms rather than to say, well it’s not reimbursed, so we won’t do it. Or we don’t care about reimbursement. Because I think if you don’t care about people’s financial health, then that’s part of the thing that can stress them and cause them difficulties. And so it’s just one more thing I put on the table.
Robyn: Makes sense. Thank you. Okay, so let’s get into talking about these issues around breast cancer detection, imaging. What are the tests that are used to evaluate the health of breasts around the country?
Dr. Sheeler: Absolutely. Well there are a number of things everybody knows about mammograms and there are different subdivisions of mammograms that didn’t used to be available. So mammography is an X-ray procedure. It does involve radiation. The first evolution beyond plain mammography was digital mammography where it could be computer assisted reading and I’m sure there are people around the world doing more and more sophisticated artificial intelligence, AI type interpretations of things. And then the latest evolution of that is 3D mammography. And so those are the main things that people are likely to get going to their doctor.
But MRI scans are occasionally used for breast imaging. And there’s a test I like that I want to talk about separately called molecular breast imaging. And then there are also other tests, there’s thermography that’s used more in the Functional Integrative Medicine world and it’s not as available in traditional institutions. And we can talk about that. And then there’s clinical breast exam. For a long time everybody was telling all their patients, oh you have to do self-breast exam, you have to come in every year for an exam, and we don’t say that as much anymore. But that doesn’t mean it doesn’t have any utility. It just means that as a primary screening thing it’s not there. So those are the main things that are used.
Occasionally to follow up on things like if you’ve previously had a cancer, you might get something like a PET Scan. But for breast imaging and evaluation to either look at a lesion initially, like is this bump malignant or benign? Oh, the other thing I didn’t put on that list is ultrasound. And so we can talk about that separately. Ultrasound is often used as a secondary imaging test to define a lesion. But we ought to talk about where that comes into the spectrum and why people would or wouldn’t use that.
Robyn: Yeah, I would like to talk about that because we have some of our followers saying, you know, after I had some kind of abnormality in my mammogram they wanted me to get an ultrasound. And I believe ultrasound is not a high radiation treatment that exposes the breasts and very tender vulnerable tissues to radiation. And we have people who are saying, I would like to just get the ultrasound, can I skip the mammogram? What are the issues with that?
Dr. Sheeler: Well the main issue with that is it doesn’t find things in time to be very helpful. And so although we can find a breast cancer, you could also find a breast cancer if it got so big that it eroded through the skin and you had an ulcer there. So it’s somewhat the same issue as ovarian cancer and things. People say, oh we should do a C-125 on everybody cause we will find all of these ovarian cancers. Well, you will, but you won’t find very many curable ones, cause you’ll still find a lot of them after they’ve already spread throughout the abdomen or to the liver or the bones. And so what we’re looking for in a diagnostic test and especially in a screening test, is we’re looking for something that finds it early enough to save your life or to make a big difference or to keep you from getting disfigured where you could just have a lumpectomy.
And so the main utility of ultrasound is to tell a cystic or fluid filled lesion from a solid lesion. And so the reason you get an ultrasound after a mammogram is the mammogram X-ray can tell you that there’s a lump there and it can tell you something about the characteristics and whether there’s calcium deposits in it. And if there are certain patterns of calcification. But it can’t really, as there are few patterns that look like, well this looks bad, this is probably going to be malignant. We need to biopsy this and go right on. But there are a number of circumstances where we go, okay, there’s a lump there, but we can’t really tell if it’s cystic like just fluid filled, which is much more likely to be benign. Or if it’s solid, which is much more likely to be malignant or need a biopsy. And so that’s the main issue.
I like, let’s just say we’re looking for basketballs on the bottom of the ocean and some of them are filled with dynamite and they’re gonna blow up your ship and some of them are just hollow and they’re filled with air and they’re just anchored down to the bottom of the ocean. So ultrasound would be a great way to tell which of the basketballs have got dynamite in them and which of the basketballs are just filled with air. But it’s not a very good way to tell if there are a bunch of things on the ocean floor that are small that we need to find before something happens.
And so once you found an area, then you can try to tell is it fluid filled and likely to be benign so you can just watch it or you can even stick a needle in there and pull that fluid out. Or is it more solid and it needs to be evaluated as if it could be a tumor. And so if you just do an ultrasound by the time solid tumors show up on ultrasound, they’re much bigger than if you find them on some of these other imaging things. And if they’re much bigger, they’re more likely to have spread to the chest wall or the lymph nodes or even to the lungs or other places. So ultrasound is a great test, but by itself it’s like too little, too late.
Robyn: Okay. So it’s giving you additional information. It’s not at all a replacement for a mammogram. How about thermography? When I went down this bunny trail and started talking to a bunch of different practitioners, I really enjoyed what you had to say about it, you seem to really maintain that neutrality or agnosticism towards the different procedures. Although I’m sure you get asked, hey, if I was your wife, what would you tell me to do? I really want your opinion as well.
I was surprised that I didn’t come back with all the functional medicine doctors I talked to saying, yeah, thermography is where it’s at. In fact, I had some real push back and I had people saying, if all you do is thermography, you are going to miss some things. So will you talk about your take on thermography?
Dr. Sheeler: Sure. So when we talk about risks and benefits, some of my patients choose to just have thermography. And they go, okay, I had thermography and I’m good with the percentage of success that that has. And if I missed something, I’m okay with that. And so, as a population, we’ve had those discussions as well around breast cancer and other cancers. And so one of the things I like to say that is slightly funny but it’s also slightly sad is the United States Preventative Task Force changed the mammogram recommendations from every year to every two years a few years ago starting at age 50, rather than before that. And there was sort of an outcry of people saying, oh my goodness, my sister might have been missed, her breast cancer might’ve been missed. And this is tragic, we shouldn’t do that. This is terrible. Why would they do that?
But on the other hand, when they changed the colonoscopy recommendations from every 5 years to 10 years and they say, yeah, we’re going to miss a few percentage of cancers. Most people said, you know, I really didn’t want that thing up my backside anyway. So I guess a couple percent is okay. And so it depends sort of all on the philosophical piece you are in terms of how much risk and how much benefit that you’re willing to take in terms of how those things go.
Robyn: What’s the difference do you think? Because it’s not like a mammography is a particularly pleasant experience from what I hear anyway. What’s the difference? Why were people okay and there wasn’t an outcry when the recommendation went to every 10 years for colonoscopy?
Dr. Sheeler: Well, I think it’s a lot, and you know, I’ve not had a mammogram and I know they have men’s days at mammogram places sometimes. And I’ve had a lot of people tell me exactly what it’s like saying, I might as well have just been laying in the driveway and they ran over part of my anatomy with a car. So I understand that it is completely uncomfortable, but it’s less invasive than something that’s actually internal and you don’t have to do a prep for it and it doesn’t take a day and a half out of your life and it doesn’t have a risk of perforating your colon and other things like that that the colonoscopy does.
So in terms of actual medical risks as well as sort of how invasive it’s perceived to be, not just uncomfortable but invasive. And then a sedative or light anesthetic, that’s a different thing. But I also think it’s just more like, hmm, okay, I could’ve had this test and maybe it would have saved my life. And so I think that’s part of the situation.
But back to thermography. The reason thermography is not used at major medical institutions and the reason that some functional medicine doctors will say, you know, that’s really not good enough for me, is the pickup rate is too low. The risks in terms of what can happen to you in the short term from thermography is like you don’t get any radiation. The good thing is it shows inflammation. And inflammation is a bad thing to have. Inflammation means there’s metabolic activity and things. There are inflammatory processes going on. And inflammation system wide is associated with heart and blood vessel disease. If you have higher inflammation markers, you’re more likely to have heart attack or stroke or things like that. If you have inflammation in your lungs, you’re more likely to have lung cancer.
So for instance, people with asthma or emphysema who take an inhaled steroid, which is an anti-inflammatory drug, they’re less likely to have lung cancer. So the information that I like that I get from thermography is it shows me there’s inflammation there. But the problem is that the pickup rate is well below mammography. And I’m going to just quote general ranges of some, and I’m sure people will have different studies that they rely on that they will say I think are more accurate than that. But let’s say mammogram is in the 80% range of detecting things that you’d want to know about and thermography might be in the 60% range. That’s just not enough. That’s just too much that you’re giving up for people to say that it’s a good screening test.
So screening tests are evaluated by their percentage of false positives and the percentage of false negatives. So the false negative means that you miss the cancer and the false positive is you said you thought you might have a cancer. So if I get a thermography that’s a false positive, the most thing I’m likely to end up with is a mammogram and then I go down that whole path. If I get a thermography that’s a false negative, I could have a cancer that grows and spreads before I go back and have another thermography that’s further advanced r before I get another kind of imaging tests. So I think that’s the main objection of the traditional medical community and medical institutions and epidemiologists who just look at populations of patients.
And so, you know, 20 years ago the Canadians said the prostate specific antigen prostate blood test is killing more people than it saved. And we went for a long time in saying, oh, well no, it’s a good test, it’s a good test. We’re doing it. And then about 10 years ago we went, uh, actually I think those folks to our north were right, in that, you know, it doesn’t find as many things as we thought early on and it finds too many things that ended up with biopsies and maybe one in a thousand people who get a biopsy die. And then it ends up leading to a lot of surgeries and radiations on patients who might have died with their cancer than of it.
And so I think there are groups of people who step back and evaluate things from just a neutral data standpoint, like population medical epidemiologists, and they tend to look at false positive, false negative rates, costs, cost per life saved, does it find it at an early stage. And by those criteria, thermography doesn’t meet the same level of performance that mammography does.
Robyn: Okay. So some people will be listening to that and their brains will be hurting. There’ll be saying, oh, I just want him to tell me which one to get. And I think that you have some criteria that you can help us with so that we as women in midlife, and we really need to be thinking about this and we’ve had many of our friends and in my case family get breast cancer. What’s the criteria used to evaluate a test for breast cancer for specific women?
Dr. Sheeler: Okay, well I could start by telling you which my favorite test is. My favorite breast cancer test is a test called molecular breast imaging. And the reason I like it is that it’s as low or lower dose than just a basic mammogram, but it sees things better. And so the breast density in terms of how much fibrous tissue there is in the breast as opposed to how much either hormone related tissue or fatty tissue is partly a dependent upon your age, your diet and your genetics. And breast density is rated D1 and D2, which are considered low density of breasts and D3 and D4, which are higher breast densities. So if you have a higher breast density, you’re more likely to one, have an imaging test that doesn’t find as much of what’s there and two, higher breast density is associated with a higher risk of cancer.
So you would ideally like a test that does a better job at analyzing higher breast density, especially if you’re in the premenopausal years because after you go through menopause and your estrogen level drops, then traditionally lots of fibrous breast tissue is replaced by fatty tissue. And I had a patient one time who she had her mammogram report and she was reading it and she said, breasts are mostly fat. She says, I’m insulted by this. And I said, that’s like if they said, you know, your skeleton is mostly bone. That’s just what they’re made out of when you’re 55 or 60 is that breast issue is replaced by fatty tissue and the fibrous and the hormone dependent tissue gets to be a much more minor component.
The good part of that is the mammogram and a lot of other imaging tests will see through the fatty tissues that are less dense a lot better than they see through that D3 and D4 dense breast tissue. So D3 and D4 breast density is higher risk and it tends to go away. So I’ve had a lot of patients that I’ve worked with for many years and their mammogram reports were D3, D4 when they were 45 and when they’re 55 they were down to D1, D2 which means that a lot of the other tests would see through them better.
Now there are two common ways if you do have more dense breasts or if you want just sort of a better view through the things that can obscure it to do that. So there are digital mammograms, there are regular mammograms and there are 3D mammograms. So 3D mammograms are said to see through dense breasts better. But the test I really like is molecular breast imaging, which was developed by one of my patients, somebody that I know his family well and it was developed at Mayo clinic. And it involves injecting a small amount of radioactive dye. You do the same thing for bone scans and stuff, but the total amount of radiation is not a high dose.
And the really good news is the squish factor is much lower so they don’t have to squish you as much as they do with a regular mammogram. And then it sees through this breast density stuff cause it’s using a different type of imaging and a gamma camera. And so it’s not gotten all that popular because the machines to do it are limited. And honestly, the people who sort of own these diagnostic pathways are very tuned to mammography and they have not said, oh well this could be done more cheaply and more affordably. Let’s embrace this technology and use it. So my understanding is, it is as good and better in every circumstance, but it’s often used after mammogram and some institutions have made it such that you have to get a mammogram first to get it.
But I’ve also seen in other states, when I’ve looked for it for friends, I’ve seen institutions that are just doing that and making it available. So if you were my wife and you say, what should I get? I’d say, whatever you want, you’re a doctor you know all the statistics and all the data. But if you weren’t a doctor, I would say you should probably get molecular breast imaging if it’s available for you. Because I think it has one, it’s more comfortable, two, it sees through dense breasts better, and three, I’ve just seen it sort out things to worry about from things to not worry about better than any of the other tests.
Robyn: Okay. So we’re always trying to help our readers get some answers when something is a little bit thorny like this. Like we help them find a biological dentist in their area or we help them opt out of a smart meter if it may affect their health and they don’t want a smart meter on the outside of their home. So I have a feeling you’re going to tell me that when we get everybody excited about molecular breast imaging being more accurate, less expensive, and most importantly much lower radiation. Are you going to tell me that it’s available to very few women? We’ll do some research on it. We’ll put it in the show notes or anything that you tell us about where people can learn if there’s even a clinic near them that has it. We’ll definitely put that in the show notes. But what do you have to say about that? Is it a rare woman who could even has access to it in her metropolitan area?
Dr. Sheeler: Don’t know the data on that. I know when I’ve searched for it for friends in different parts of the country, it was easily able to find a center within a fairly close distance of them. But what I don’t know is how widely adopted the technology is. I know that it’s patented and made by major equipment manufacturers and that a number of medical centers have it. But I honestly don’t know the answer. Compared to mammography, it’s more difficult to get, but how much more difficult? I don’t know.
Robyn: Okay. And I think you mentioned that sometimes some physicians will use the MRI for breast imaging. Did you want to say more about that? Why someone might use that?
Dr. Sheeler: Sure. So the circumstance I’ve seen MRI used is it can find very tiny things. And as the machines get more precise, you know, each year they can see a three millimeter lesion, then they can see a two millimeter lesion, now they can see a one millimeter lesion. And so they’re seeing smaller and smaller things. And so the group of patients that I’ve seen that used for are people who have extremely high risk for breast cancer, like they have the BRCA-1 or BRCA-2 genes and they have a very strong family history of breast cancer. Those are the kind of folks I’ve seen get MRI’s. And so you say, well, you know, most MRI’s can be done without any kind of contrast and it seems safer and it’s not radiation, so why wouldn’t everybody get that?
The problem is it has a very high false positive rate, at least from the last time I studied it. And so high false positive rates mean a lot of people end up getting a biopsy. And so, if you think a mammogram is bad, biopsy is further down the road in terms of, you know, at least local anesthesia, somebody sticking a needle there, you’re waiting around for a week for results. And so that goes back to the whole screening thing we talked about is like percentage of false positive, percentage of false negatives. They don’t think to even factor in how much worry and how much distress and how much pain and agony it is to sit around and wonder during that week before you get the biopsy back whether there’s something bad. They’re just looking at what percentage do you find that are true positives and what percentage do you find that are false positives.
And there’s a thing called Bayes’ theorem and it works for heart disease and it works for biopsies and stuff. And Bayes’ theorem says the validity of a test depends on the underlying percentage of disease. And so for instance, if you take a 75 year old man with super high cholesterol, high blood pressure, and many other cardiac risk factors and he’s got severe chest pain and you say, uh, well we did an electrocardiogram and we did a treadmill test stress test, and it was negative. So he doesn’t have heart disease. Well if his underlying risk of heart disease when he came in to see you with chest pain radiating to the left arm was 90% and the treadmill stress test was only 78% accurate, then you’d say, well, I’m still worried that I missed a serious disease and so I’m going to go on and do an angiogram on this person anyway.
And so if the underlying incidents or probability of disease is higher, then a more aggressive test is indicated. And the same thing happens is if your underlying risk of breast cancer is higher than the chance that any lesion that shows up is going to be cancer goes way up. And so then it’s worth the trouble to say, okay, we might put you through 5 biopsies in 10 years, but we’re going to find a breast cancer early if you don’t want to do something drastic like have a prophylactic double mastectomy. And a lot of people say, well, I don’t think I want that at all. So okay, well what’s the most aggressive thing we could do? We could use an imaging that finds a lot of things early, even if it finds some of them that are not true positives, it’s going to find the true positives earlier. So that’s the situation, is it depends on your underlying risks that you would have a breast cancer each year and in those circumstances you might use a test like that.
Robyn: Okay. Interesting. That was such a great cross section of everything that we might think about when it comes to breast imaging. Hopefully we didn’t miss anything. But how about this? I would say 85% of our audience is women. They are concerned about their husbands. They are caretakers for, often a man, often children, often adult children. This is a really kind of catchall question. Are there some fallacies that your patients present you with all the time that you really like to debunk? Like false beliefs people have out there that you might want to share with us an alternate perspective in your many years at really prestigious institutions and in your medical practice?
Dr. Sheeler: Hmm. I guess one thing that I would probably share with you is the whole cholesterol hypothesis. Is that everybody with an elevated cholesterol is at significant incident risk of heart disease and that if your cholesterol is low, you’re not at risk of heart disease. And so let’s start with the latter one, half of people who have heart attacks have low or only mildly elevated cholesterol, if you just checked the total cholesterol and the bad cholesterol, the good cholesterol and triglycerides. If you start breaking that down to more sophisticated tests that tell how much of your cholesterol is oxidized low density cholesterol, whether the particle sizes are bigger or smaller, whether they have elevated clotting factors or inflammation along with the cholesterol, then you start to get much higher results.
So I guess I’d say myth number one is if your cholesterol isn’t elevated, you aren’t at risk for heart disease. Just as you age from all the things that we have in our life and diet and, and other combinations of genetic factors and lifestyle things, you’re at some risk. And then if you have elevated cholesterol, if your total cholesterol is elevated, you might have mostly the good cholesterol or the size of your particles. You know, a bad cholesterol is called the LDL molecule. But if you have big LDL particles, they’re like beach balls, they bounce off the artery walls. If you have small LDL cholesterol, lots of particles, they’re like bullets, they penetrate the artery walls and cause problems.
And so I think, since heart and blood vessels disease maybe kills half of or more of Americans that sort of having an understanding that you’re at risk for it no matter what and you need to do healthy behaviors, you need to monitor your blood pressure. It’s certainly valid to monitor cholesterol and in our practice we monitor a number of different sub factors beyond that. So if it’s normal, you still need to worry some. And if it’s abnormal, you need to look at your overall risks and you probably would benefit from some more sophisticated analysis rather than just the total good, bad and triglyceride valuations.
Robyn: Okay. I’m glad you brought that up actually because my extended family, the Romneys, were recruited to be in a study of large families that have never had any heart disease. And there’s not any known cardiac event among my huge family that came across the plains, with just 8, 10, 12 children in each family. So there’s just thousands of us and it’s just a strange family and they wanted to study us. But here’s the thing and your comments make me want to go ask. I’m going to go text my entire family, all my brothers and sister and parents and find this out.
My overall cholesterol is 99 and it has been my whole life and I used to congratulate myself on that, but there is more coming out. Like you said, glad you brought that up, that we used to think that high cholesterol is bad and overall low cholesterol is good. But so my issue is yes, I have low LDLs and that has always historically been like, Yay, great job. But then I also have low HDLs. So am I going to be the first one in my family to have a heart attack?
Dr. Sheeler: No, probably not. And I’ve talked to lipid researchers. If your cholesterol is that low then your HDL doesn’t really matter as much because HDL is like taking it back from the arteries and other places for reprocessing. So if there’s not that much to take back then you don’t have to worry. So the other thing that really is reassuring for me is probably all of your relatives who were susceptible to that died off either before they got here or on their trip across the plains and the ones that reproduced were the strong and vital ones.
But I like to go a lot by a family history and genomics. And so I’ll do genetic tests on people and I go, you’ve got five blood clotting genes, but you’ve got three that protect you. And they go, nobody in my family ever had a blood clot and I’ve done all sorts of surgeries and stuff and never had a clot. Then I go, okay, well the protective ones are probably balancing out and helping you. So I would say just a family history like that is very reassuring.
And so in one of my first practices, I had a guy who had triglycerides to like 2000 and you know, you drew his blood in our little office and part of it just looked like cream. And the guy was 80 and everybody in his family lived to like 105. And so I thought, okay, well in his case it’s probably not that bad because nobody in family, you know, based on all of the protective genes and all the other factors they have that are beyond our ability to measure, nobody in his family had had disease in that realm.
And so I like to take that in as part of the whole equation. And so I think your family history is very reassuring. I think a total cholesterol of 99 is good and it doesn’t really matter how low your HDL is in that circumstance. But you also need to have enough LDL around to make hormones out of. So you make your estrogen and your testosterone and your progesterone and your vitamin D out of that same cholesterol steroid ring. And so there are things that we would monitor for that. And people who get low cholesterol late in life, maybe they have cancer and they’re not eating, that’s a bad sign as well. But overall, just from a general prevention standpoint, I think you’re in the clear.
Robyn: Interesting. So yeah, I kind of have this theory and it’s not even strong enough to call it a theory, it’s just more of a question that I have that, you know, it’s like I’ve had low hematocrit and if I go to give blood, I’m usually pretty borderline for whether they’re going to reject me. And so I just have to like drink a bunch of water before I go or No, I drink very little water and then my hematocrit allows me to give blood. It’s ridiculous.
Dr. Sheeler: Yeah, it’s because you’re dehydrated. That’s the reason it goes up into normal range. Yeah. Brilliant.
Robyn: Yeah. It’s just a weird little fact that I learned about myself and it makes me wonder with that and the cholesterol issue and some other things that I often wonder if certain things are normal for me or they are normal for my family. And you mentioned much earlier in our conversation that these averages ranges that we’re given in medicine so often, you kind of rushed through that thought and I wanted to bring that back for just a quick second. That an optimal range would look really different than the charts that we’re usually given that are comparing us to averages, which may be pretty useless as a baseline. And I hear people say, my doctor told me I was great because I was like on this whatever percentile for whatever it is, cholesterol. And it just feels not very meaningful to me. Do you have some of the same concerns?
Dr. Sheeler: Yeah, I definitely have some of the same concerns. I mean if you are twice the normal range then there’s usually a disease going on. If you’re one point over you may not be any problem at all. But within each of those things, in one of our other companies where we do direct to consumer lab testing, we’ve defined optimal ranges that we think represent like the best physiology, where the membranes are the healthiest, where you have the most reserve, where you’re the least likely to get problems.
And so, you know, there are some of the liver tests that if they are up at the upper limits of normal, it might mean either your system is processing too much alcohol or that you’ve got a lot of toxins in your system, a lot of pesticides and herbicides and stuff like that. And so there are implications for that. So the people in the highest percentile of pesticide, herbicide, general toxins in their system have a much higher incidence of getting diabetes at a not very elevated weight. Whereas people with the lowest percentages of those things tend to not get diabetes even if they’re a bit heavier.
And so a lot of these have to do with optimal health. And so that’s what we try to look at for our patients. And that’s what we try to assess and educate them about and to say, okay, your numbers are normal, but let’s look at your risk. Let’s look at your family history, let’s look at your lifestyle. Let’s look at the things you’re concerned about and see if we can get you to the point where you have more resilience and more ability to handle things that come the road. And I believe that has to do with what’s optimal physiology rather than what’s just normal in a thousand people walking down the street with a lot of different medical conditions and a lot of different lifestyles.
Robyn: Okay. I have one more sort of philosophical question for you and that is what are you excited about in medicine? What do you think is going to change in the next 10 years that’s going to be just mind blowing for all of us that’s positive for the patient, that makes you excited about being a doctor going into the future?
Dr. Sheeler: Sure. So I think we’re going to get to truly personalized medicine. And now we’ll say, oh, well, you know, this blood pressure drug has been studied in your gender and your race and it looks like it’s probably okay and so just take it. But we do genomic tests now that says, you’re likely to react to these types of medicines, you’re likely to react to Statin drugs and so we should find another alternative. Or these types of blood pressure drugs are going to do better for you. So I think the combination of first genomics and proteomics and then understanding, you know, what all the genes and all the microorganisms in our microbiome contribute to our metabolism. I think all those understandings are advancing rapidly and the ability to get that information cheaply is going down dramatically year by year.
So I don’t think it’ll be too long. And I hope it’s during the time I’m still practicing medicine in the next 20 years where everybody’s got a chip that says, not just that it identifies us and tells anybody who wants to snoop or follow us too much about us. But it tells us these medicines are likely to work for you. These nutrients are likely to be deficient. These are things that you can do for optimal health and these are things you’re more susceptible to and here’s stuff you can do about it.
So I think we’re just at the dawn of the era where things are, one, the knowledge is expanding, two, the artificial intelligence to process that knowledge is expanding and then three, the ability to analyze genes and enzymes and proteins and other molecules and get information. And we’ll be able to put that in a giant thing and give you truly precise personalized medicine rather than just one size fits nobody.
Robyn: That is exciting. And it reminds me of, you know, advances in oncology. I’m very historically a critic of oncology, that branch of medicine. But I do see, you know, I’ve known two people who coded in their first or second chemotherapy treatment. One was a toddler and she didn’t make it. And one of them was my aunt and she was in a coma for a month and then said no thanks to chemo. And that was about 15 years ago and she’s still alive.
But it reminds me of how now we can test people for their sensitivity to specific chemotherapies so that if someone’s going to have such a massive reaction to one specific type of chemotherapy, then maybe there’s another option. So while that doesn’t solve all the problems with chemotherapy, it certainly seems like a potential for advancement. So I agree those are some positives. We always like to think about what the good things are because sometimes we talk about the problems in medicine or the struggles. Tell my listeners where they can learn more about you and what else you got, link them to some great stuff from Dr. Robert Sheeler.
Dr. Sheeler: Sure. Well I think the main thing I would link them to at this point is our medical practice in Scottsdale. We have a small medical practice after leaving a large institution and it’s called Next Level Concierge Care. And the website is www.nextlevelcare.us. And so it’s a dot us instead of dot com. And we sort of lay out our philosophy and how we try to build all of the options that people are looking for on top of traditional Western Medicine and on top of scientific understanding, but have it be very personalized and as precise as people want to go into.
Robyn: And your wife is also a medical doctor and is she participating in the clinic?
Dr. Sheeler: She is, yeah. My wife is Dr. Angela O’Neil and she was also with me at Mayo and we’re in practice together here in Scottsdale, Arizona.
Robyn: I think I’d love to interview her too sometime. So I know you’re very busy and you’ve just been so generous with your time in the call we had before this and this interview. So very grateful. And it’s nice to know you. Thanks for this interview, Dr. Robert Sheeler.
Dr. Sheeler: My pleasure. Thank you for having me it’s a privilege.
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