The Boob Bus

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org senior editor Jamie DePolo .

Jamie DePolo: Hello, thanks for listening.

Our guest today is Rena Vanzo, a licensed, certified genetic counselor who wants mammograms to be fun. She created The Boob Bus, a mobile breast imaging unit that also offers genetic testing, so women can have mammograms in a spa-like environment.

Rena, welcome to the podcast. I'm so excited to talk to you about this.

Rena Vanzo: Thank you, Jamie. I'm looking forward to this also.

Jamie DePolo: So, where did this idea come from? I mean, I know there are mobile breast imaging units, but I've never heard of one called The Boob Bus, and I've never heard anybody else say they want mammograms to be fun. So, how did this come about?

Rena Vanzo: I knew you were going to say that, and I bet a lot of the listeners are also thinking, fun, that was the last word I would use to associate with my mammogram. But really, I think it truly is becoming a more fun experience, at least when people have it with us.

So, the way that this idea sort of came about was really exciting for me, and I think the idea really found me. So, I was a genetics professional for a number of years. I was growing a little bit tired of working in that corporate world every single day. I was thinking about becoming a business owner, and I turned 40 and had my first mammogram, and it was fine. You know, it was a typical experience. I didn't quite know what I was walking into. I didn't know what to expect, and it was fine.

Couple weeks later, I found out some family members of mine from the Midwest had been diagnosed with breast cancer. They called me to talk about the genetic reasons, you know, that could be at play in our family, and it just kind of occurred to me, hey, I would like to start a business. I think that mammogram experience I just had could be improved. There are a lot of forms of genetic cancer that run in families.

And so, I thought why don't we put all of this together and try and make it more, you know, educational, more supported, more exciting, and give people a place where they can talk about that. What are their fears? I'm going to go in with my sister, or my best friend, or my mom, and whether they're both getting mammograms or not, at least they could be there for each other right before and right after the procedure to help with that informational aspect and that emotional supportive aspect.

Jamie DePolo: Sure. So, why I have to ask, too, why mobile? Because it sounds like what, you know, you were thinking about it could have been like a brick and mortar place. But why did you opt for mobile?

Rena Vanzo: Yeah. That's a great question. I mean mobile, to me, seemed really obvious. You know, I grew up in a small town in central, rural Illinois. We have a lot of rural communities here in Utah, where I'm located, and by the way, when this idea was in formation, Utah was ranked 48th out of 50 states for women getting their mammograms, and one of the reasons was people not having good access to a hospital where there is a mammogram.

So, it seemed obvious to me that if I was going to be able to serve the most women in need that we would need to go to the woman. And not only is it a location issue, but also, I mean, just the convenience. I live very close to a number of different large hospitals, right now.

But it can be really intimidating to have to drive to the big medical center, you know, to navigate all of the construction and all the different parking garages there might be, and find the right place, or to find childcare, you know, when you have to go that far away. So, if we were going to make an impact the way we wanted to, we had to bring the mammograms closer to the women.

Jamie DePolo: Okay. That makes sense. So, you are a genetics professional. You came up with this idea. How do you go from the idea to actually implementing it? I mean did you have experience running a business before? What sort of prepared you to get this off the ground?

Rena Vanzo: Yeah. I think there are a couple different things that I would attribute to that, and I mean, one of them, I think, is just, in general, my personality and my kind of drive as a person. I've always been very caring, very personable, and just, I'm so driven to kind of work directly with the people, and that has kind of propelled me through all of the stumbling blocks that I've run into and helped me get through them.

But also, I was really lucky and had this amazing opportunity where I'm at, here in Utah, there is a business program specifically for people starting a business. And after, you know, you're approved as far as your student capabilities, and after your business is approved, I was accepted into this program. It's called the master's of business creation, and it's almost like they help you develop a blueprint for your business.

You know, how to take all those skills of mine, those previous job experiences, and really turn it into a business that is going to do good for the community, but also actually survive as a business and make it as a business in today's day and age. So, that MBC program was crucial in me getting this started.

Jamie DePolo: Excellent. So, tell me what happens on The Boob Bus. What, you know, it pulls up. I know you do more than just mammograms. So, I'm walking in. What happens?

Rena Vanzo: You would just walk in, and I think the first thing you would probably notice, Jamie, this is something that a lot of women comment on is, wow, this is not like I expected it to be when I heard mobile mammogram. I mean people come in, and it's a very calming, inviting presence. We have some kind of light pink neon lights on the inside of the bus.

There's a really cute wall that's got pink bras all over it, just sort of a very feminine motif that makes you feel almost like you're in a spa environment, more so than a hospital. You know it doesn't have the sort of really intimidating white walls and long hallways. The lighting is soft. Instead of paper gowns you would typically get at a hospital, we give each woman a warm robe that says The Boob Bus on it.

So, it's just playful, fun little details like that that make a woman feel more like a woman, more like an individual that's being cared about, you know, rather than just a number that's going through a system. So, typically, on a busy day, there will be three of us on the bus. I'm the medical receptionist. You know, I'm there to greet people, to check them in. I also drive the bus myself.

Jamie DePolo: Did you have to take special training for that?

Rena Vanzo: I did. I had to get a commercial driver's license for that. Yes.

Jamie DePolo: Okay. Okay. 

Rena Vanzo: So, that would be fun to talk about more, if we have more time, but anyway, I'm there, and I also have two mammogram technicians, typically, if it's going to be a busy day, because, you know, we know that each woman's time is important when she comes, and we're able, if a woman is already pre-booked in our system and she, you know, books online, once she gets on the bus, she's gone in probably about 10 or 15 minutes. 

It can be a really fast procedure, and so, if we do have people, say we're going to be at a clinic, one day, or if we're going to be at a company, serving employees, and we have people booked, pretty frequently, through the day, I want those mammogram technicians to be able to trade off, so they can take a break they need, they don't feel like they're having to be too rushed with each woman, and they both have excellent training, really personable, and really like to provide more education.

I mean, for example, women have probably heard or remember that they were asked not to wear deodorant or to take their deodorant off when they went in for a mammogram. And as many times as I've heard that, no one really explained to me why that is. Well, many deodorants, the ones that are not natural, have aluminum in them, and aluminum can appear as a calcification on the breast mammogram, and a calcification is one sign of cancer.

So, we don't want that extra element that could kind of confuse the mammogram procedure, and so, we like to explain this and tell people this and really take our time doing that with them, and that's been something people have commented on and they really appreciate from us.

Jamie DePolo: Oh, that's great. Now, what happens, say somebody has a questionable mammogram? You know, you're mobile. You're in a bus. Is the mammogram read right there? Would you do another one right away, or does someone have to go, then, to another facility? How does that work?

Rena Vanzo: That's a really good question, and I bet a lot of our listeners are thinking about this and recalling their own experience, and again, I think this is another component where people don't get enough information about their procedure or what the whole process can look like. So, there are two kinds of mammogram types. So, what we do on The Boob Bus is called a screening mammogram, and the word screen, it can mean a lot of different things.

But in a medical or healthcare context, it really means there's no issue at hand, there's no problem, this is just a standard procedure that's happening for a preventative purpose. So, that's why, as women, we're supposed to go in once a year, once we're 40, even if there are no issues, you know, and that is a screening mammogram, and so, we are licensed to do these screening mammograms.

So, no issues, no lumps, no concerns. It's just for a screen, and then there is a separate kind of mammogram called a diagnostic mammogram, and that is done if there is a concern. Maybe I'm doing my monthly self-breast exam and I feel a lump, or I have a screening mammogram and a lump or a calcification is seen, I can't really feel it, but it's seen, and in either of those circumstances, then a diagnostic mammogram would be ordered.

And it is a little bit different, you know? In that case, we're really zoning in on that area of concern. Maybe more pictures are taken. Maybe a different kind of, a different piece of equipment is used that will magnify the area of concern. So, a screening mammogram and a diagnostic mammogram are slightly different in that way, and so, that, I think telling women that before they come on The Boob Bus, or right after they come on The Boob Bus, it's really important to say, hey, this is a screening mammogram.

You know if we see something, then that would put you in this diagnostic category where I would call you, we would get you set up at a facility that is credentialed and prepared for that process. And the thing that people don't realize is it's pretty common to get a callback.

Jamie DePolo: Right. Right. I was going to say I've been called back, and that happened, right, like, the radiologist looked at it and then said I want you to stay, we want to take some other views. So, I guess that's… I probably didn't phrase the question correctly, but I guess that's what I was wondering. 

So, if a woman has the screening mammogram on The Boob Bus and maybe there's something there that, you know, you're not quite sure of, looks a little suspicious. I guess that's what I'm wondering. Is it read right there, or is it read later, and then you would call the woman and tell her, like, okay, you need to get set up with a diagnostic mammogram?

Rena Vanzo: That's right. It would happen later, Jamie. Yeah.

Jamie DePolo: Okay.

Rena Vanzo: So, we just do the screens on the bus. The radiologist reads that. The radiologist is not there, on site, to do that in real time. That's another requirement, actually, of a diagnostic exam, that a radiologist is there in the facility, and it's probably worth mentioning. I bet a number of our listeners are kind of recalling their own experience and thinking about this, and it can vary depending where you live, what the hospital systems are like in your area.

You know, sometimes women are, I guess you could say lucky, in that, you know, they get that diagnostic kind of add-on right there if a radiologist is on site and has read that image. But some women have to wait a couple weeks. Unfortunately, there are some hospital systems, right now, that have such a shortage of radiologists that they may have to wait a couple months to go in for their diagnostic, and that, it really breaks my heart.

It's something that we're trying to do, you know, work with the facilities around here, how can we make this whole process more efficient in a given geography so that women don't have to wait that long. Because it's very unnerving. I actually had to do that myself. I got that callback and had to go in, and I chose to go to an out-of-network hospital provider because the one that was in-network for me was backed up longer than I was willing to wait.

So, that can be a frustrating point, and you know, when I do call women who are in that sort of experience, and that's happening, you know, I like to let them know, hey, this is, you know, a lot of women get this callback. It does not mean there is cancer. In fact, most frequently, it is not cancer. It's just something that the radiologist couldn't tell and wanted to be sure about.

So, that's another thing that we're doing on The Boob Bus is really tracking that closely so that we can give women some idea, you know, what is the chance that you'll be called back? And if you are, what is the chance that you're going to have to go in for a biopsy? So, we want women to know what that looks like. 

And another thing that's worth mentioning, Jamie, is the rate of women having a callback, it's higher if they've never had an image done before, if they've never had a mammogram done before, or if it's been many years since their last mammogram. Because no matter where you go for your mammogram, that facility should be requesting your prior records from the last place you had them, so the radiologist can compare.

You know, what did Jamie's breasts look like 12 months ago, when she had her mammogram, compared to now? How much did that change? And so, if there's nothing to compare it to, we can be more alarmed about things. And so, that's why it is really important, even if there was nothing wrong, why you need to go every single year to keep that up, so we can monitor your individual breast health and how that breast changes.

Jamie DePolo: Yes. Excellent advice. Excellent advice. Now, you offer genetic counseling and testing, also, on the bus. Does somebody have to ask for that ahead of time, and how does that work?

Rena Vanzo: So, the genetic testing has become a lot easier to get than even a couple years ago. What it involves is taking a part of somebody's genetic code, and most often, that used to be through blood draw, but even a cheek swab or a spit sample, a saliva sample, are both proven, completely acceptable ways to do testing now, and so that can easily be obtained on the bus.

So, I do have genetic testing kits that are on The Boob Bus, and there are lots of different providers, laboratory providers. Everybody's test is a little bit different, but in the context of breast cancer, the most popular gene or genes to look at are called the BRCA1 and BRCA2 genes, and what I've decided to do is add -- there's about approximately 30 genes, altogether, that have been associated with either breast cancer, ovarian cancer, even other cancer types, like colon, prostate, melanoma.

So, genetic testing is not just for women. It is something that all genders can have. And in the, you know, I'm here, doing these screening mammograms, people are already thinking about their cancer risk. So, many people do just ask us. I don't need to know in advance. They can just tell me, hey, I'm interested in that genetic testing kit, too. Can I submit a saliva sample today?

And we will do that, and as a genetic counselor, I can go through some of the pertinent information, what risks there are, what benefits there are, and the process is really pretty easy. And the second question I always get is does insurance pay for that? And insurance does and can pay for genetic testing, but the requirements are incredibly variable from one insurance plan to another.

And it really depends on a person's own history, you know, has that woman specifically had cancer, or is there cancer in the family? And so, again, if you go back to what I said earlier, there's screening and then there's diagnostic in the medical, you know, world, and for genetic testing, you can kind of think of it that way, too. I'm offering this testing as a screen.

You know there's really nothing in particular needs to be wrong, or there doesn't need to be any red flags. Because we are looking for these changes in genes like BRCA1 and BRCA2, where if we found it, it would mean major helpful information for a person, for their doctors, about how frequently they should get screened, again, not just with breast and ovaries, but also colon, pancreatic cancer, skin cancer.

So, if we find, and the word is “pathogenic,” which is a very technical term, but because everybody has two copies of all of these genes, the question is does that gene work like it should, or is there a change in that gene that stops the gene from working like it should to prevent cancer? And so, if somebody has one of these pathogenic changes, for example, means they should have a breast imaging done every six months, not just every 12 months, and insurance would cover that extra screening exam.

And maybe it's not just a mammogram. It's a breast MRI. Breast MRI is done every year. Mammogram is done every year. So, the woman has something every six months, or as another example, there are genetic variants that mean a person is more susceptible to the radiation risk and actually shouldn't have a mammogram. They should have a different form of a screen.

And so, if one of these pathogenic variants is found, it's highly actionable in what we do and how we care for that person and then, potentially, their family members. Because if a person has one of these genetic variants, there's a 50-50 chance that their children would have it, that one of their parents has it, their siblings have it. So, it's really important to kind of think about that in the family context.

But anyway, back to that point about screening. I offer it just as a cash pay because the insurance, in many cases, actually in all cases, wouldn't approve it as a routine screen. They might approve it if, okay, Jamie comes in, and she has cancer, you know, and she's deciding am I going to do just a lumpectomy, or am I going to have a double mastectomy because I know my breast cancer risk is very high, not just now but in the future?

Jamie DePolo: Sure. Sure, and talking about all that, this just occurred to me, have men ever come on The Boob Bus? Because I'm wondering, obviously, not as frequently as women, but men do get breast cancer. You know the BRCA1 and BRCA2 genes also, if you have a mutation, also increase the risk of prostate cancer. So, I'm just curious, has a man ever come on there?

Rena Vanzo: Yeah, and actually, one thing that's also been really great is men have walked on the bus and have said, oh my gosh, my wife is at home today, but she really doesn't like going to the hospital, could she come on here and have a mammogram? And so, I love to see that sort of family support and community support, too. Because we do go to employers' offices, you know, where employees can have it.

But to more directly, you know, kind of get to your question, Jamie, we can't do mammograms for men. You're absolutely right that they can have cancer. Men can have breast cancer. About 1% of all breast cancer diagnoses occur in men. So, that is possible, but it wouldn't be a screen if a man had a mammogram. You know he would be having one because, oh, I feel a lump, there's something here. So, that automatically puts him in that diagnostic category. So, we don't do mammograms for men. 

However, we have done genetic testing for men who, perhaps, have a family member, you know, one of their parents or sister was found to have a BRCA1 genetic change, or at an employee event, where we will go, you know, and serve the women with mammograms and then people of all genders with the genetic testing, because, again, it's a screen, and anybody can have this to see if they have one of these high-risk colon cancer variants, you know, that would change how frequently they should have colonoscopies or guide what kind of treatment they should have. So, men absolutely have been checking it out, have been inquiring, and have participated in genetic testing.

Jamie DePolo: Excellent. That's good to know. So, I know one of the ways you market The Boob Bus is that people can have parties at their houses. Like, they can reserve it. It comes to their house. They invite their friends over. So, how does that work? Do you have to have a certain minimum number? How does a Boob Bus party work?

Rena Vanzo: We've been pretty flexible. We're really just getting going, which is incredibly exciting. We got the bus in February of this year, and so, we've been, and I have been in that program I told you about, the master of business creation program. So, we've been sort of slowly getting out there and maybe doing events just once or twice a week at clinics so far, and we have our first really big party next weekend, and I'm excited, incredibly excited about it. 

It's a block party, a couple women who live next door to each other and who have a, kind of a great, really active friends group and community of women, and they've decided to do kind of a playful promotion of it, calling it Tacos and Tatas. It's a Mexican food theme, and so, they're all bringing something to have a potluck, and then we're going to be doing the mammograms, and so, I just talked to the kind of women in charge.

And what I will typically do is ask for a small fee that will go towards the services that those hostesses get, depending on the size of the party, how far I have to drive, perhaps $100 dollars or $200 that will go towards their genetic test. If we have a party and a group of women, they may also be interested in some elective procedures, like Botox. That's something that in an early survey I did, a lot of women expressed an interest in.

So, I do have a nurse who is a registered aesthetician who could come and do Botox, as well. So, then there are maybe women getting mammograms, there are may be some getting a genetic test, getting Botox, two or three of the above. So, it really just depends what that group of women want, if they're due for their mammogram. And then also something I haven't mentioned yet that is worth mentioning, we also have a dense breast ultrasound on the bus.

And we're the only mobile unit in the country that has this automated breast ultrasound. It's called an ABUS, and this is really, it's very popular out on the East Coast, where there have been good laws and regulations created where insurers need to cover additional screening if women have dense breast tissue. Unfortunately, that sort of regulation hasn't caught on yet where I'm at, but I'm expecting and hoping that happens.

But a lot of our listeners may remember when they got their mammogram report, the report says, you know, Jamie, your breast tissue is categorized as type -- it'll be either A, B, C, or D -- and that goes from fatty to dense, has nothing to do with your cup shape, the cup size, the way your breasts look or feel. It's all about really their genetic makeup and their components, how many glands, how many ligaments, how many fibrous tissues, milk ducts are there.

And if a woman has Type C or D dense tissue, that can hide cancer on the mammogram. And that's really not great because dense breast tissue is more likely to become cancerous, as well. And so, women will get these mammogram reports, and they really feel incomplete, you know? It says we didn't see anything, but you have this dense breast tissue, consider another form of screening.

And so, dense breast ultrasound and mammograms really complement each other well because they can see different types of signs of cancer. So, we do offer the dense breast ultrasound, as well, and I've had a lot of women who called and said, hey, I just had my mammogram, but I really want this breast ultrasound because I know I have dense tissue, and I know the mammogram can't see everything.

Jamie DePolo: So, is that -- I'm wondering about insurance coverage for that -- because I know, in most states, I believe, there's either no or very low cost charge for a mammogram. I'm assuming that there would be an additional cost for the ultrasound because I know some places don't cover additional screening. The U.S. Preventive Services Task Force just put out their new recommendations. I'm not even going to go there because I don't think they went far enough, but that's just me, personally.

Rena Vanzo: Right.

Jamie DePolo: But if somebody did want that, I'm assuming that's an extra cost?

Rena Vanzo: It again, it really varies depending on a person's insurance and their own family history. So, I'm working really hard, right now, to get insurance contracts with the insurance companies in my area. And in some cases, they are receptive to that, you know, what is that medical code, and can we get that added, and can we get that covered? 

So, that is something I'm asking for. There have been a few women who have come back with dense tissue, and we can tell, we also have technology that tells us, right there on the bus, is this woman an A, B, C, or D? And in some cases, I have taken that information, I've taken their report and either sent it in to their insurance company or called them, asked permission to add on the ultrasound, and in some cases, that's possible and they're approving that.

So, I can do it for a cash pay rate, or people can pay with their health savings account, flex spending account, cash if they don't have that, credit, of course, or possibly insurance. So, it's really variable, and again, that feels just so frustrating because not all women have equal access to that, which is a shame. 

So, I think, you know, these podcasts, like you're doing, and you know, marketing efforts, like The Boob Bus is trying to do, we just really need to raise awareness for these issues and have people that help us, you know, lobby, and go to the lawmakers, and get this stuff written in because it is really unfair when women don't have that same access to these lifesaving processes.

Jamie DePolo: Absolutely. Absolutely. Now, you said you just got the bus in February. So, we're just a few months in, but where do you see this going? Like, do you want a fleet of buses? Do you want a brick and mortar place and a bus? What does the future hold?

Rena Vanzo: Yes to all of that, Jamie. That would be the dream, and it's been so fun to get phone calls. And you know, I can remember actually a couple women who called me and said how far do you go, and I said, well, where are you, and she said California, and I said, no, I'm in Utah, so I don't think that can happen yet. But you know, that really does make me think. I would love to replicate this and to have this more broadly available. And you know, that idea of having a brick and mortar place, you know, a set building where we can go, I think that is also a really good option.

You know, the bus can go to people, but then, you know, if there is, let's say, a more expensive, larger piece of equipment, like maybe I get a breast MRI at some point. You know, that wouldn't be as mobile or couldn't fit on the buses like we have them, but it could be at that brick and mortar center, and we could do diagnostics at a place like that, perhaps, where a radiologist is always planning to be. So, we're exploring all of those different options.

Jamie DePolo: Oh, that's great.

Rena Vanzo: And you know, a fun component I do want to mention is that I lovingly refer to this first bus as Doris Jean. That was my grandmother who was just an amazing role model and inspiration to me, and she's a breast cancer survivor. She was. She survived breast cancer and died many, many years later, after a long and happy life. But it's kind of a reminder to me, you know, why I'm out there, doing this every day. And you know, Doris Jean's sister, my Auntie Pat, Patsy, she also fought breast cancer.

So, maybe number two is going to be Patsy. So, I like, you know, really personalizing all the parts of this business because that's exactly what breast cancer is. It's very personal, and it doesn't just affect the woman. It affects her kids, her parents, her siblings, her partner, her school community, her coworkers. So, I think that's just a nice reminder that we are all connected, and we're all in this together.

Jamie DePolo: Absolutely, and the whole idea, too, of sort of personalizing the mammogram experience, as you said what you're trying to do with this startup, yeah, I mean, I'll admit it. When I go in to get my mammogram, it's very clinical. It's, you know, it's in a, it's not necessarily in a hospital, but it's in a clinic, and you know, you go from one room to another, and nobody really knows your name, and it's just impersonal. Whereas what you're talking about sounds, I have to say it, much more fun.

Rena Vanzo: Yeah, and you know, people, and I've had people who've said, you know what, I'm good to keep going where I've been going, and there is nothing wrong with that, you know?

Jamie DePolo: Sure.

Rena Vanzo: Everybody is so individual, and people like what they like, and the point about our society is that nothing is one-size-fits all. Women are all different, and for some people, that may work. They may prefer it, and others may not. But one of the elements that I've kind of come to learn is, hey, that's great, but I also want you to know if there is a reason you don't want to try The Boob Bus, let me know why that is. Because some people think, well, I've always gone to this hospital, I need to go there again.

Okay, but remember, we are asking for your records from that hospital, so we can compare last year's to this year's. There's this whole, it's called continuity of care. You know, let's make sure that care continues. And the whole community wants people to have that, and you know, I'm not going to be upset if, next year, Jamie comes back and says, you know, I didn't really like my experience on the bus.

I don't think that's going to happen, but if somebody did say that, I would say, no problem, but where are you going? Make sure you're having this every year, as you should. We're going to send those records to the brick and mortar hospital so you get that continuity of care, whether you're coming to us or going somewhere else.

Jamie DePolo: Absolutely. I think that's really the important thing, as you said, that somebody gets a mammogram every year or as often as they need be, whether that's six months or more frequently, depending on their history.

Rena Vanzo: Right.

Jamie DePolo: Absolutely. Rena, thank you so much. This has been so great. I'm thrilled to learn about The Boob Bus, and I wish you so much success with it. I would love to see some out here on the East Coast.

Rena Vanzo: I hope we get there at some point. I'll let you know, Jamie.

Thank you for listening to The Breastcancer.org Podcast. Please subscribe on iTunes, or wherever you listen to podcasts. To share your thoughts about this or any episode, email us at podcast@breastcancer.org, or leave feedback on the podcast episode landing page on our website. And remember, you can find a lot more information about breast cancer at Breastcancer.org, and you can connect with thousands of people affected by breast cancer by joining our online community.