Expert Advice on Genetic Testing, Cancer Prevention & Care Disparities with Dr. Rachel Brem
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Welcome back to We Can Do Hard Things. We're back with Dr. Rachel Brehm, who's sharing with us all the information we need in order to advocate for ourselves with doctors when it comes to detecting breast cancer as early as possible, because that's the key. We got to know about it as early as possible when it is curable and treatable.

So how to become our own best advocate. She shares with us what to say and when to push to make sure our care is what it needs to be. Okay, Dr. Brehm, I want to ask you about something really important. Black women and breast cancer. Black women have a 40% greater chance of dying from breast cancer than white women. What do black women need to know to do differently?

Or is it the entire medical establishment that is failing black women and they don't need to do anything differently? The medical establishment needs to do things differently.

Yes, and yes, and yes, and yes. So Black women die 40% more frequently than white women stage by stage of breast cancer. It is a multiple complex issue. One is that they're at increased population risk. And in fact, the American College of Radiology two years ago identified them as a high-risk population. But there are other high-risk populations like Ashkenazi Jewish women who have a tenfold increased risk of having a genetic mutation that affords them

a much higher risk of developing breast cancer. So in the general population, it's one in 400 who have this kind of mutation. In the Ashkenazi Jewish population, it's one in 40. So if you're in a room with 40 women, at least one of them is likely going to have a mutation that gives them a 60, 70, 80% lifetime risk. But Black women, it's multiple factors. One is access. We have to

be cognizant of that. Now, the good thing is that that's becoming more known.

And we're talking about that more. But the thing that worries me is we can't just give Black women additional access to mammography. And you might be surprised that I'm saying that. But when we're doing this, we have to be careful to make sure that we give them excellent care because we know that centers of excellent, excellent care, subspecialized care, radiologists who are dedicated breast imagers end up with better outcomes because they're

the care is better, that they are cared at centers of excellence. So as we become more aware of the healthcare disparity, breast cancer is not an equal opportunity disease. And, you know, we have to be mindful that all high-risk populations have the conversations with their doctors, but also that we educate them. And, you know, that's why

What a wonderful thing you're doing. Because if you think, you know, there's so many people who have come up to me and said, but I don't understand. Why isn't my primary care doctor telling me all this? Right. And you think about they've got to tell you about cholesterol and a high blood pressure and exercise and nutrition and breast cancer and lung cancer screening. It's a lot. Right.

And that's why at the Brehm Foundation, with the book No Longer Radical, we are putting some of the responsibility on women themselves and doing all we can to educate them so that if their visit to their primary care physician doesn't discuss

you know, essential additional screening, we have helped them understand that that is critical. That, you know, if they have a family member, they have to start five to 10 years earlier. That if they have dense breasts, they need additional screening. And that is not tomosynthesis. That is not essential additional screening. But we know that Black women's pain and

risk and all of that is routinely dismissed by the medical profession. So put us in the room and what do these women say and do in the face of institutional dismissal?

I don't understand how we could dismiss anyone, let alone a population that we know die at a higher rate. One of the things that we're trying very hard to do, and we are as a healthcare community doing, is increasing the number of Black women in clinical trials. And there has been a well-deserved distrust of clinical trials in some Black populations and some Black communities that

And that's well-deserved, right? But we have to move beyond that because we have personalized medicine. You know, we have personalized drugs. We have drugs for ER positive, PR positive breast cancer, for HER2 positive breast cancer with incredible outcomes and results.

We are now developing, and one or two have been FDA cleared, drugs for people with mutations, people who have advanced breast cancer with BRCA mutations. But if we don't know what your genomic makeup is or response to drugs, then we can't develop drugs that are as directed, personalized, and targeted. So there is a big effort, and that is paying off, including more Black women in clinical trials,

And the awareness of the health care disparity is helping us to begin to alleviate these health care or impact disparities.

the consequences of healthcare disparities. And we have some technology that's going to help us too, like artificial intelligence. At GW, where I work, every single mammogram is evaluated by artificial intelligence. And we use a wonderful AI called Transpara by a company called ScreenPoint. It's the only AI that's used as a second reader in Europe. In Europe, screening programs, government-sponsored breast cancer screening programs, two radiologists have to read every mammogram to try to

capture the earliest cancers. But now because of the paucity of breast imagers, they're allowing this particular AI to function as the second reader. And we know that it can find breast cancer earlier and it can help general radiologists function as well as subspecialized radiologists. So in the military, actually, our service people is another really underserved community where the healthcare is by generalists and there isn't enough of it.

And so, you know, one of my pet projects now is trying to get AI into the military and into veterans hospitals because they really deserve that as well.

And you said that the density, that there's a new rule passing that will be, when will it be effective that everyone will be told their density? September 24th. So the FDA's mandate will go into effect with specific language, September 24th, 2024. And that will tell everyone whether they're dense or not dense, or will tell them specifically if they're extremely dense or heterogeneously dense. Yes.

Dense or not dense. Dense or not dense. Okay. And that will be within the context of a mammogram. You go get a mammogram and then on the results of that mammogram, it will tell you your density.

By law, every woman who has a screening mammogram is required to get their results in late terms within 30 days of their mammogram. And on that report will be their breast density. And although it doesn't say A, B, C, or D, as you point out, but all women, whether they're heterogeneously dense or extremely dense, should get additional essential screening to find these hidden cancers. Because even with women with heterogeneously dense breasts have hidden cancers.

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Breast cancer is such an interesting thing. There's nothing in medicine like it, right? So if you have a strep throat, you get an antibiotic, right? If you have a broken bone, they set it and hopefully it heals. When you have breast cancer, and Amanda, you just went through this, they say, oh, do you want a lumpectomy? Or maybe you weren't offered that, but many women are, right? I know you were saying, do you want a lumpectomy or a mastectomy? Well, I really don't want either. I don't really want breast cancer.

And how could I possibly integrate enough information with all the nuances to make that decision? You need to know, yes, you might be, for most people, a lumpectomy is enough.

But your risk of recurrence is about a half a percent per year. So if you're 40, by the time you're 80, you know, you've got a very significant chance of a recurrence and that might be okay, but it's got to be made eyes wide open. Yes. Right. You've got to know that if you don't have bilateral mastectomies, if you have one, that your reconstruction is not going to be the same. That's okay. But we have to embrace the differences of women, of people, of choices, right?

Even though some choices look so obvious to us, having done this for as many years with as many people, I've learned that everybody is different and we have to embrace that as long as it's done eyes wide open with information. They're all good choices as long as they're medically sound. There are many different choices and the choices for different women are different. And

and that's okay. I love it. One thing I took from, which dovetails with what you're saying, but one thing I took from the book is that everyone has a bias. You as the patient have a bias going in. Either I want to be as aggressive as possible, or I want to be as conservative as I can be while still addressing the medical issues. Your doctor has a bias. There is no robot doctor. They are either on the side of

There is overtreatment going on and we are treating too many cancers and we shouldn't even be looking for certain cancers because they're not going to arise to be catastrophic or they're over here with a super aggressive approach or somewhere in the middle. So your job as a patient is not to pretend.

Like your doctor doesn't have a bias and your job is to suss out what is the bias of your doctor and is that bias aligned with yours? Because what they're telling you is not gospel. It's their approach. That's right. Right? So you need an approach that matches your approach by educating yourself, by reading, by listening, by that what feels warm to you and match up with a doctor that feels the same because it is not...

They are not all the same. That's exactly right. And it turns out that if you have a male breast surgeon, you are 35 or 40% more likely to have a lumpectomy than a woman. And I have to say many of my friends and colleagues who are physicians who've had breast cancer have

you know, more than the general population have opted for mastectomy and even contralateral as you did the other side prophylactically, because we have seen women who have made educated decisions with recurrences on the other side, and maybe in hindsight, they would have made a different decision. But it's very important to understand that there is a tendency now for minimal surgery. And that

That's okay. But understand that if you choose a lumpectomy, that very likely you're not going to be equal. You're not going to be symmetric. That every time you look in the mirror or you run around naked, that you see the consequences of being a cancer patient. I love my reconstruction. They're symmetric. They're wonderful.

I love them and never for a second, even though the surgery up front was much longer and more difficult, do I regret that? So I think...

There is a bias now towards less is more, and that might be good for some, but it's not good for others. And as you say, suss out the one, the doctor that sees the world as you do, and you will find that doctor. There's so much on a woman diagnosed with breast cancer, and this is one more on her must-do list, but it is a must-do.

I just want to talk about overdiagnosis for a second. Can I talk about that? Please do. I'd love to, especially in the era of Viagra on demand. I'd love to know about our theory of over-medicalization of women's breast cancer. So I don't know... How does Viagra on demand... Well, I just think it's like...

A man wakes up in the morning and it's his birthright to be prescribed Viagra and any other thing that might ail him for 30 seconds. Women, it's the idea of removing a breast cancer from you is like, whoa, that's a little much. Don't you think we're being a little aggressive there? I just think it's an interesting double standard that we have about what constitutes over-medicalization. Okay.

Okay. Proceed. That's my bias. Yeah. That's interesting. I agree. And that's why I love that suss out. I'm going to borrow that if that's okay. Please do. Okay. So overdiagnosis, there are some cancers that don't have the biological potential to kill. All right. And on ductal carcinoma in situ, some of the low grade ones are

a smaller percentage of them will never develop the biological potential to kill. And that's over-diagnosis. The problem that we forget to add as a breast cancer survivor, patient, whatever, we don't know which ones they are. Right. Right. So really it's not over-diagnosis. It's under information. That's right. We will develop

biological markers, genetic information that will eventually allow us to say, oh, that cancer has the potential to become a killer cancer, but that one doesn't. And until we do that,

If someone said to you, you know, you have a cancer, two thirds likelihood, you're not going to die from it. One third, it might become an aggressive, invasive cancer. We don't know which one it is. Do you want to treat it or do you not want to treat it? And to me, that isn't over diagnosis. That's under information because someone who stood in those shoes of having a disease that might can maybe will shorten your life. I,

I don't know. I kind of want to live. I love life. It's under information, not under diagnosis. Some of those will become bad actors. We know that. So again, it's the bungee jumping versus crossing the street. If you like to bungee jump, maybe you don't want to treat it, right? If you look both ways before you cross the street, well, maybe you'd like to treat it because you will have the best opportunity for a cure. Love it. Is there,

any way you could give us an overview of what all this genetic testing is and how sure I don't even Abby is more of the guide for us on this which I'm so grateful for well sister actually was the real guide right right so what is genetic testing why is it important where do we get it what the hell is BRCA love that question so we have cells in our body every day that go awry

And we have proteins in our body that clean up those arise cells. So if we didn't have this cleanup mechanism, then we would get cancer a whole lot, but we don't because we have this aberrant cell cleanup mechanism. Like a Zamboni. It's like a Zamboni. Like it goes like, it's like a Zamboni. Okay. Great. But these are proteins and people who have genetic mutations are

have proteins that are malfunctioning. So the gene that codes them has a mistake in it. It's misspelled. So it doesn't do what it's supposed to do. The cleanup mechanism is broken. And so cells can become cancer a whole lot more often.

And there are now actually 70 genes that have been identified as a result of large data. And in fact, we tell women who were tested more than five years ago to get retested because we have so much more information. And, you know, as Amanda had a variant of unknown significance, right? We're learning the significance of those every day, every year. So the protein malfunctions. And so your cell goes awry and...

We don't have a way to clean it up. So the cancer grows. So it's a tumor suppressor gene.

that malfunctions, and therefore the cleanup mechanism doesn't work. It's important to understand, like maybe in your family, it can come from your father as much as your mother. So if you have no cancer on your mother's side of the family, but a lot of cancer on your father's side of the family, breast, prostate, early, both breasts, other cancers, every gene is associated with various different cancers,

then you can get it from your father as much as your mother. It's an autosomal gene. So

How do you get tested? Right? Very easy. It's not a blood test anymore. You can spit in a tube. You can get it online. There are a lot of different 23andMe. The Brem Foundation has an association with Color Genomics. When it first came out, it was thousands of dollars. Now it's $200. If you put the code Brem into Color Genomics, you get 50 bucks off. We're trying to partner with lots of different entities to be able to offer information

everybody this opportunity. The best way to do it is to see a genetic counselor, because then if the results come back, something that you need help understanding, you will have that help. But color genomics, which is what I know the best, has genetic counselors that will help you if you do come back with the gene. And, you know, this is by no means an advertising, but I'm

I'm sure the places that test have it, or you can go to your doctor or you can go to a breast physician who can help you get that. So that's what that gene is. Okay. And then what do you do? So, so you get your results back, you go to your doctor or you go to the website, you get the test for genetic testing, you spit in the thing.

You get it back. It's a list of a lot of letters and different. No, it says there is or there isn't a deleterious mutation. That's the word they use. Oh, but it will tell you which one it is. OK, but, you know, you'll understand. Everybody will understand it. Then what do you do?

So if your genetic testing comes back and shows a deleterious mutation is what they usually say, you should definitely call your primary care provider as well as go to a place that has a high-risk surveillance program. So usually cancer centers in your neighborhood make an appointment to see one of the breast cancer doctors. You don't have to figure out the path. Most of us have patient navigators that will take you along this journey because it's way too much information

to integrate all that right up front. So we know that we have patient navigators go someplace that has a high risk, a cancer center, or your doctor will send you to a cancer center that has what we call a high risk surveillance program. And almost invariably, there are patient navigators that will help you make the appointment for you or give you a list of what you need to know to start on this journey.

journey. That's exactly what happened with me. I was at my gynecologist and I said, I've been recently thinking about my grandmother and great-grandmother having either ovarian or uterine. We don't really know. Is there genetic testing? She gave me the genetic test. When she got the results back, she sent them to me and she said, I recommend that you go to one of these cancer prevention centers. I went there, then they took all my family history and

and looked at the density and plugged that all into a little formula and said, okay, you're three times the average likelihood of developing the cancer. So we want the extra screenings. So it was very, very simple in my case. It's very important to see an expert because they can help you understand both what other cancers, what surveillance approaches, what you

you can do to prevent cancers, prophylactic mastectomies, oophorecteries, getting your ovaries out, or what kind of testing you need to find the earliest cancer for the genetic mutation you need. It's not a one size fits all. So BRCA1 and 2 were the first

And the other thing is for people to know that we still have a lot of genes we haven't understood. We don't have them all defined. So Christy Teal comes from a family that makes every sense that there may be a mutation, but in fact, there isn't. And is it that there isn't or that we haven't identified that mutation yet? My family, we do have a mutation.

And we come from a family that looks like has a mutation. But it's important to realize a couple of things. One is that some families don't have a lot of women, a lot of Ashkenazi Jewish families that might have lost great parts of their family during World War II, but may not have large families. Or you may come from a family that's largely men for whatever reason. So it's important to factor that in and a genetic counselor can help you.

So that's what you do. You get professional advice because it's overwhelming and there's a lot of information and every gene has a different strategy. But you also have to suss out people that have your approach as well, aggressive or not. Both right, as long as it's information infused and eyes wide open.

Okay. And I think it's so important when we talk about breast cancer, you know, I work at George Washington university. I can't tell you how often a professor at the university and some other department, I have the very difficult task of telling them they have breast cancer. And they say to me,

Rachel, I can't have breast cancer. I go to the gym every day. I'm vegan. I'm just the right weight. Nobody in my family has breast cancer. You must be mistaken. And the answer is that we talk a lot about risk. We talk about density. We talk about family. Three quarters of women who have breast cancer have no other risk factor except being a woman. So I really want-

Three quarters of women who have breast cancer have no other risk factor other than being a woman. That is correct. Sometimes you're at the airport and you see, how do you prevent breast cancer? We're really just on the threshold. We really can't yet prevent breast cancer. We have to minimize our risks to getting it, but nobody's immune. And that's a really important point to share with the people who are listening to this.

Because just because you don't have any of the things we talked about doesn't mean you can't get breast cancer. So then is the suggestion of that. And by the way, being a woman, men get breast cancer. Non-binary people get breast. It's really just anyone with breasts. But does this point to the idea then that if 75% of people who get breast cancer die

It doesn't have to do with genetics or dense breasts. Is it environmental? You know, the American Cancer Society says that, you know, somewhere between 40 and 60 percent of breast cancers are environmental or at least have environmental component. But, you know, we really can't do much about that. And that's why we have to screen everyone. We can't just screen people that have dense breasts or have

family history. And in fact, we have to go further than that. So that's very important. But some people think that every woman should be tested for a genetic mutation because Mary Clark King, the woman who identified the first mutation, said that any woman who dies of a genetically induced breast cancer is a failure of medicine. Because had we known early enough, had we followed early enough, had we

done considered prophylactic mastectomies, we could have saved a life. So

that's a really important thing. And, you know, for me, breast cancer has been every part of my fiber, right? It's been what I do every day, my vocation, my avocation. I actually feel very fortunate that I sit on the board of a number of companies that develop new technologies. I've had been privileged to take technologies through FDA. So, you know, one of the thoughts that I really like to share is growing up, I really hated breast cancer. And then in my thirties,

I really, really hated breast cancer. But now I have some new perspectives that, you know, I have passion and that's a gift, right? And I've been given a gift, a lifetime gift of trying to help others, of taking something that's been very, very difficult and

for me as a child, as a daughter, I mean, Lord knows as a mother and trying to find the good in it and flipping it as much as possible. So, you know, I think there's many life lessons for me, for everyone who's your one family has been impacted by breast cancer and you will never not be impacted by it. But, you know, I really,

have the highest admiration for what you're doing. You're taking a very difficult situation and you're helping others. And, you know, I'd like to think that there is some good in it. Better not to have it. All right. You don't have to have every disease to know what, how to help people. But I am very grateful as both someone whose breast cancer is infused in every fiber of her being. I'm very grateful for what you're doing. Likewise. Thank you for

everything that you've done or doing and really grateful for all this information. Absolutely.

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In closing, I was just going to say, Glenda, do you have any other questions? I do. I love your question. I do. So one of my favorite doctor hacks is just to, after they tell me all the things I just say, okay, so like if I were your daughter, what would you tell me to do? And it's always an interesting little teeny shift that often works and sometimes doesn't for your children.

What testing exactly do you tell them to do? What do they do yearly? At what year did you start? I just want like you, mom, what do you tell your kids to do in terms of testing? Secondly, I know we can't control environmental things and we don't know what the hell is causing the cancer even. So what do you suggest to your children they avoid or include in their lives that you suspect might be environmental triggers?

pretend the pod squad is just sitting in your living room. Okay. What are you saying? So I, I love that you asked that question and yeah,

I often say to my daughters, it's a blessing and a curse to be my daughter. Right. So I don't talk about them to respect their privacy. Sure. But, you know, so obviously from, you know, my mother had breast cancer. I had breast cancer. My aunt had breast cancer. And we're Ashkenazi Jews. Right. You don't have to be a genius to figure out where we're coming. So I'll talk about you and we can be family. Great. So.

First of all, for Glennon, I'd say you should get an MRI. Right. And I don't know if you're I try to figure that. I don't know if you know who's the older sister. So I know Amanda's age. I don't know your age. Forty eight. Forty eight. Forty eight. Forty eight. I'm 40. I'd say you should get an MRI. Right. I think you should consider getting an MRI every year.

Okay. I think you should get genetic testing because I know Amanda has a variant of unknown significance.

maybe that will be one of those variants that we'll learn is significant. Maybe not. If you don't have it, you don't quite have to get out of jail free card, but you kind of have it get out of jail free card. I do have it. I do have it. I got tested and I do have it. So, so then I think you should definitely get an MRI. I think you should get a mammogram every year and an MRI every year. And with a high degree of confidence that if you do develop a breast cancer, hopefully we'll find it early. If you said to me,

you know, Rachel, I want to do everything I can with the family. You know, you have a sister who at 45 had breast cancer. You have a variant of a non-significant. And you said to me, Rachel, I want to think about options for prophylactic mastectomies. I don't think you're off the table on that, right? It's a big thought, but I think you're going to be safe with annual MRIs.

I don't know Abby's history, so it's very hard for me to address that. But, you know, I would say the algorithm for everybody is if you don't have dense breasts and you have no other risk factor, a mammogram finds way north of 90% of breast cancer. Okay. If you have a dense breast, get a mammogram every year and an MRI, probably separated by six months, but that's kind of weak data. It doesn't matter if you get it at the same time, six months.

you know, or if you have dense breasts and you have the opportunity to get an ultrasound,

or molecular breast imaging, or contrast enhanced mammography, that's probably enough if you don't have a family history. If you do have a family history and you have dense breasts, particularly if the breast cancer was early, or if you have a greater than 20% lifetime risk of developing breast cancer, you should have an MRI every year. That's pretty clear. And that is what the American Cancer Society recommends. So it's not that complicated.

It does get complicated when insurance doesn't cover it, things like that. But hopefully we address some of that that I can publicly say. I'd say think about reading No Longer Radical. It alludes to some of these things. There are ways of trying to stack things.

the odds in your favor and I'll just leave it at that. Thank you. But always with truths, always with truths. You know, I want to be very clear about that and always with evidence-based medicine. We can't make things up. We can't make blank up. You know, you can't extrapolate from one study to the next. We really have to

practice the best evidence-based medicine. And the other thing is, and Amanda, this speaks to you, but to everybody, we have to make the best decisions we have at the moment, right? And we can't beat ourselves up that in two years from now, we learned something new that would have changed our decisions. So for instance, I'm BRCA positive. I had a bilateral mastectomies and I had chemotherapy, right? Mm-hmm.

The chemotherapy that I chose to have, and that's another thing, right? In what other universe of medicine do people ask you, what chemo do you want? Right. But we still do with breast cancer. And there's so many other things about breast cancer that I wish I could share with you, but nobody would give a bracket person the chemo that I had. Obviously, no.

worked well. It's been north of 25 years, but we have to make the decisions that we have now. And we have a lot of good things too. Like there's something called cold capping now. So women who get chemotherapy can wear these cold caps. We were the first in DC to have it. Other places do gratefully as well. What it does is it puts very cold water around, you know, on your

circulates in a cap on your cap. So it makes the blood vessels close down. So the chemo doesn't get to your hair follicles. So less hair falls out and you don't have to be the chemotherapy cancer patient, you know, that constantly reminded that you're bald. So, you know, we, we are trying to,

get personalized therapy, directed therapy, immunotherapy, but also trying to help with the emotional piece of it and understanding that that's really different for everybody. Thank you. Beautiful. Thank you for your generous sharing of all of this. Thank you. All of this information is so important and thank you. Really so grateful.

Yeah, I feel the same. I feel very grateful for this opportunity and our paths have crossed and I feel very lucky for that. So thank you. Thank you. We will link to your book and to the foundation and hopefully that will be a wonderful resource for people who want to learn more and

want to help their friends learn more. And because there's like this, this pressure to self-advocate and it's important and true. It's also so cruel that the moment we need to self-advocate is the moment we're in the most trauma and the most confusion and the most flight of flight. And so there's also this feeling I have of wanting to like others advocate while we are healthy and not in the moment. What do we do to advocate for those who

maybe won't be their best self in the moment of their trauma. So all of us should go research this so that we can be an informational, steady touch point when our friend or our sister or when it's really just a when the person comes to us. Yeah.

And at the Brent Foundation, whenever we have an educational event, you know, we ask for three things at the end. We ask for you to advocate for yourself. We ask that if you learn something new, you share it with five people you love. Right. That's how we're going to get that information. And of course, we ask for support. But the most important thing is if you learned anything.

share it with five people. And, you know, and I'd be very grateful. There is a lot of information at bremfoundation.org. It's a way of really educating very useful information and also no longer radical. So there's a lot of information there and people can reach out to me directly as well. It's always a privilege to be able to help. Okay. And I just want to say this. What do you want to say? Pod squad. I know you're listening on your phones and I know you've got friends. Get your phone.

Right when you turn this off, text your friends, get five people on a text thread and say, my mammogram was this date or my mammogram is this date. When is yours? And let's start a tree, a pod squad texting tree.

Of accountability. And accountability. Oh, there she goes. There it is. This is what all of our dinners sound like is somebody says a word and then she'll smush them together. Anyway, I think that one of the things is that we get really stuck inside of our heads and the fear of I don't want to get this test or I'm afraid to get this test because I don't want to even get the results and have to go down that road.

But it's easier if we're in groups. It's easier if we can feel that community even in the testing process. So here we are. For me, the way my brain works is like mammography, ultrasound, MRI, right? And so get on a text chain with some of your friends figuring out which ones you've had, if you've got dense breasts or not, if you need...

extra testing with the ultrasounds or the MRIs. Do it. Get your phone out now. Do it now. You literally might be able to save one of your friend's lives. Yeah. It can be the new what's your sign? It's like, so what's your breast, boob, tissue? What's your density? And remember that not knowing doesn't mean you don't have it. Right? Knowledge is power. Not knowing is never good. Yeah. Right? Mm.

And if you have it, you can do something, whether it's cancer, genetic mutation, higher risk. But if you don't know, you can't do anything about it. That's right. Thank you. You're wonderful. Thank you. I am so grateful that our paths crossed. Amanda.

There are so many things, so many firsts that will come your way. I remember the first time I bike rode. I love to bike ride. So the first time I bike rode after my surgery, I thought I'd never do that again. Just like the world can seem a little sweeter from hardship. Thank you. Thank you. Thank you. All right, PodSquad, go text five people. If you're like me and can't think of five, start with three. Okay.

Five. You can think of five people. Fine. You're such a show off with all your favorites list. Okay. We love you. We can do hard things. Bye. Pod squad. Thank you for investing in your health and your future and your family by receiving and listening to this information.

please do do the loving and protective thing that Abby suggested and text five friends. You can share these two episodes with them to make sure they know about breast density and the screenings we need, and then tell them when your appointment is and ask them to check back when theirs is scheduled. I can't imagine anything a friend could do that would be more important and loving than that. Before we end this episode,

Please know how deeply grateful and amazed I've been with your outpouring of love and support through this whole process. It really does feel like we're all connected in a family and we have to look out for each other like family. And that's what so many of you did when you called in to share your hard-won wisdom from walking through this so that we could all learn from your experience.

Here's just a few of the beautiful voicemails you've been sending. Thank you, thank you, thank you for being in this community and for sharing your love, advice, and stories so openly. It truly is a gift and a service. Here they are.

Amanda, thank you so much for the podcast about your diagnosis and encouraged me to call my doctor because I have dense breast tissue and my dad had breast cancer, which is kind of rare. My aunt and my cousin all had breast cancer. So I...

I feel like I'm a little bit more high risk and I didn't know what kind of density I had. So I called and found out the 40%, but I still should be getting something besides the 3D mammogram. So I'm going in next week to get a, they said start with an ultrasound screening. So I'm doing that next week and all thanks to you. And it was fantastic.

quite funny when I called my doctor and said, yeah, I think I want to find out what kind of breast tissue I have. I have a friend that was dying. I mean, that just sounds so funny. I referred to you as my friend. Oh my gosh. I just, I listened to your podcast all the time and I feel like you guys are friends that we've never met. But anyway, thank you. Thank you. Thank you.

Hi, Sissy. It's Katherine. I wanted you to know that I'm a cancer researcher and based on everything that I've heard that you have shared, I believe that you have such a great prognosis as somebody who has an immediate family member who's a cancer survivor and then as somebody who really cares about you because they really identify

with a lot of the things that you're working on and the growing that you're doing. I just wanted you to know that I'm in your corner along with all of the rest of the We Can Do Hard Things fans. And I'm just thinking about you. Thank you so much for sharing what you're going through with us. Love you.

Hi, this is Paula. I'm 52 and I have been a listener since episode one. I just wanted to respond to Amanda to tell her I have processed my cancer exactly the same way. Do not have any shame about it.

You are the same exact type of person that I am, that you were in the tactical approach of getting things done for everyone else. You will process the emotion. I am once into this journey, and it takes a while, but I'm wishing you all the best. It is a scary, scary journey to have little kids through. My children were six and nine when I was diagnosed.

And I have a very rare form of lymphoma that was found in my breast tissue. So a lot of the similar things with MRIs, the mammograms, we don't see it, we see it. Anyway, I just wanted to say, I wish you all the best. Prayers are being sent and you ride this cancer ride however you will. And that is, there's no right or wrong way to do this at all. There's no right or wrong way. You do you and you will come out of this an even bigger warrior. Love you guys.

Hi, my name is Katie and I just want to say thank you. I was recently diagnosed with early stage breast cancer and just had a mastectomy and I'm going through reconstruction and have a very similar journey to Amanda. And I'm so thankful that people like you are putting this out there because it's so important that people and women know about this happening to younger and younger women all the time. It's so scary. I'm 49 years old and this came out of left field for me. So best of luck and thanks again.

My name is Jenny and I just wanted to say a big thank you to all three of you, but specifically Amanda for sharing where you're at in the messy middle of this breast cancer diagnosis. We're all cheering for you. I so appreciate your candidness and openness and I thought it was so beautiful in the second episode where you were all kind of doing a repair around that moment of

Amanda saying that she refuses to take any shame for not feeling her feelings right now. I just thought that moment and the follow up was so powerful. And then also, I just appreciate so much because I just got a call back that I need to go for a more thorough mammogram and that I have dense breasts, but now...

I already know more of what to ask now because so many people are just told dense breasts. And so now I know so many more questions to ask. So I just wanted to thank you for that. You, by sharing this are also saving lives and helping other women advocate for what they need. Thank you. Thank you. Thank you. I'll be thinking about you.

My name is Rebecca Ann. I am a writer in San Francisco and a big fan of your podcast. I was diagnosed with breast cancer in 2021. One thing I like talking about is what to say to someone with cancer and how to help. For me, the most valuable thing anyone ever said to me was when one day my husband took me to chemo, he just turned to me and said simply, "Thank you. Thank you for doing all of this for us. Thank you for having surgery and going through chemo."

I've been working on writing about how useful that was for me to hear, and I've made sure to thank other cancer friends for all they are doing to stay alive and persist. Thank you, Amanda. We need you. I thought that might be a helpful tip for Glennon and Abby, as I'm sure you must be wrestling with what exactly to say to Amanda, who, as she pointed out in the end, has to go through this alone. Thank you all for what you do.

Hello, my name is Becky, and I'm sure that you have received hundreds of thousands, if not millions of calls of people wanting to

give their well wishes to all three of you and tell their cancer story. I am a 10 year cancer survivor and I have to say that I processed much like Amanda so far, what we've been told is processing. I was never emotional about it.

I didn't cry about it. I was just like in planning mode as Amanda and I are a lot alike in that way. I had a unilateral mastectomy on the left side and they actually removed seven lymph nodes in the chain that had also been infected with the cancer. But I know you guys will all get through this. I know everything is going to be okay.

best wishes to all of you, especially Amanda and her family. Thank you so much. Really love the pod. Listen all the time. Don't know what I did before you guys came into my life.

If this podcast means something to you, it would mean so much to us if you'd be willing to take 30 seconds to do these three things. First, can you please follow or subscribe to We Can Do Hard Things? Following the pod helps you because you'll never miss an episode and it helps us because you'll never miss an episode. To do this, just go to the We Can Do Hard Things show page on Apple Podcasts, Spotify, Odyssey, or wherever you listen to podcasts. And

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We Can Do Hard Things is created and hosted by Glennon Doyle, Abby Wambach, and Amanda Doyle in partnership with Odyssey. Our executive producer is Jenna Wise-Berman, and the show is produced by Lauren LaGrasso, Alison Schott, Dina Kleiner, and Bill Schultz.