What should we do with dense women?
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Women with dense glandular breast tissue present a challenge—and one with high stakes.
Their tissue type is capable of hiding small abnormalities, they have a documented increased risk of breast cancer, and should they have a tumor it is more likely to have certain aggressive characteristics (as reported recently in the Journal of the National Cancer Institute).
Anne Richards, Clinical Development Manager, Women’s Healthcare, Carestream Health
As radiologists, you’re aware of these facts. But what about the women whose mammograms you interpret?
My recent post about breast density focused on the Governor of California’s decision to veto legislation that mandates that we inform “dense” women following their mammograms of their breast type and the implications, including the possible benefit of additional screening.
Similar legislation has passed or is pending in several U.S. states, but this veto highlights the importance of radiologists voluntarily providing this information.
Informing a woman of her breast density presents another dilemma. How useful is that information without recommendations on what to do next? What’s more, the medical community has yet to establish a protocol for them, including what modality should be used for follow-up.
For example, trials indicate that ultrasound combined with mammography provides increased detection in dense breast tissue. So should asymptomatic women with dense breasts be screened will full ultrasound in addition to their annual mammogram? Will insurance companies pay for the radiologist’s additional time? Can and should technologists be trained to do this screening instead?
In my opinion, we should not wait for mandates from the government to address this issue. Insurance companies, radiologists, and physicians need to work together to develop a standard of care for women with dense breast tissue. It’s a new horizon for our field—but one that will lead to brighter futures for the patients we treat.
What steps is your practice taking to notify women about the risks associated with dense breast tissue?
kimwhit
Thanks for sharing this – we cant wait for this to be legislated – too many women (this is a friend’s actual situation) are getting this:
“Dear _____:
We are pleased to inform you that the results of your screening mammogram performed on ____, are normal, and did not show any significant change since your prior study. It is recommended that you have your next routine screening mammogram in 1 year.
The corresponding radiology report for this “normal” mammogram, sent by the radiologist to my treating physician read:
INTERPRETATION: Breasts are very dense (76% -100% composed of dense fibroglandular tissue). This decreases the sensitivity of mammography. Lesions could easily be obscured by overlying breast tissue.”
Less than TWO (2) MONTHS later, the MRI she demanded because of the persistent, painful lump she felt, found two large advanced stage, aggressive tumors in her “normal” left breast.
If she had followed the recommendations of her clinic’s “normal” notice letter and waited another year for her next mammogram, she probably would not be here to write about her experience today.
Her surgeon told her she saved her own life by insisting on an MRI because her cancer was entirely obscured by her dense breast tissue and never would have shown up on a mammogram. He also said that a cancer the size of hers took 2-10 years to develop; and in the early stages of the disease it would have been considered a local disease, which could have successfully be treated with only breast sparing surgery e.g. lumpectomy only; no chemo, no radiation, no long-term disability.
Carestream Health
Excellent feedback and thanks for your comments. I have spoken to many radiologists that not only comment on breast density in the letter to the patient but recommend consultation with their referring physician about further follow-up such as ultrasound and MRI. Also if a woman feels a lump or has pain she should mention this to her referring physician but especially to the technologist if she has kept her routine screening. The patient should then be given a diagnostic mammogram NOT a screening exams. Many sites will then do focused mammographic views and/or ultrasound. Of course the insurance company would have to approve. If there was a standard of care for women such as your friend it would greatly streamline the process and possibly improve time to diagnosis and treatment.
Jill Duggan
It is my first glimpse of density as a factor that affect the chance of a woman to acquire Breast cancer. well i quite enjoyed reading your article.
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