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Dense breasts increase the risk of developing breast cancer and make it harder to detect cancer with a mammogram, but many people don’t realize that this is a significant risk.
Starting this week, all mammogram reports and result letters sent to U.S. patients will be required to include an assessment of breast density. Final Rule Regulations requiring mammography facilities to inform patients of their breast density will come into effect on Tuesday.
Breast density is a measurement of the amount of fibroglandular and fatty tissue in a woman’s breasts. The more fibroglandular tissue there is, the denser the breasts.
About half of women in the U.S. over the age of 40 have dense breast tissue, the radiologist said. Dr. Kimberly FeiginInterim Director of Breast Imaging Services and Director of Breast Imaging Quality Assurance at Memorial Sloan Kettering Cancer Center.
“We talk about breast density for two reasons. One is that dense breasts can make it harder to find cancer on a mammogram because dense breast tissue, which is made up of glandular tissue and supportive connective tissue, looks white on a mammogram, and cancers look white on a mammogram,” Feigin says.
In other words, because breast tissue appears white on a mammogram, just like a lump or tumor, dense breast tissue could hide cancer on a mammogram.
“The second reason breast density is important is because denser breast tissue increases a woman’s risk of developing breast cancer,” Feigin says.
The new notification requirements do not outline specific next steps for patients with dense breasts, but encourage women to talk with their health care providers to get a clearer understanding of their individual risks and determine the screening plan that’s right for them.
Although it is recommended that all women start having mammograms at age 40, some women with dense breasts may Additional imaging options for breast examsUltrasound and MRI scans, etc.
Joan Pushkin, a 64-year-old breast cancer survivor who has been campaigning for more than a decade for a national requirement for women to be informed of their breast density, said the new rules were long overdue.
Pushkin, in her mid-40s, noticed a lump in her breast but wasn’t particularly worried – she had had a mammogram about eight weeks earlier, which came back normal.
But she returned for a diagnostic mammogram, and the radiologist told Pushkin, “We couldn’t find anything.”
Pushkin thought the technician had mistaken her for another patient.
“It was a big facility with several waiting rooms, and I simply assumed she’d returned to the wrong room,” Pushkin said. “I said, ‘No, I’m talking about women with large lumps that you can feel,’ and she said, ‘Oh, you have dense breasts. That would be very hard for us to find.’ I remember sitting down and saying to her, ‘Wait a minute, what?’ I didn’t even know what that sentence meant.”
Although the mammogram did not reveal any palpable lumps, Pushkin underwent further tests and had a breast ultrasound.
“And there was a definite lump,” Pushkin said. “I was diagnosed with breast cancer. Within 20 minutes, I knew I had dense breasts, I knew I had breast cancer, and I knew it had been missed because my breasts were dense.”
Pushkin was diagnosed with the disease at an advanced stage and underwent eight operations and eight chemotherapy sessions as part of his treatment.
“It came back a few years later, I underwent 30 radiation treatments, and now I have lymphedema, all because it was caught at a late stage,” said Pushkin, who has testified before the FDA and co-created a website about breast density. DenseBreast-info.orgFeatures resources on breast density.
“I felt that because I was not informed that I had dense breasts, I was effectively denied the opportunity for an early diagnosis.”
Standards for everyone having a mammogram
so far, An estimated 39 states and the District of Columbia Some states already require some breast density information to be reported in patient mammogram result letters, according to a tracking system on the DenseBreast-info website, but state mandates can be worded differently and don’t always require health care providers to inform patients about the risks, leading advocates to push for a national mandate.
When the FDA’s new rules go into effect, informing patients about their breast density will become mandatory nationwide.
“This will provide a uniform standard across the country so that every woman in every state will be told she has either dense breasts or dense breasts when she has a mammogram,” said Dr. Wendy Berg, professor of radiology at the University of Pittsburgh School of Medicine and Magee-Womens Hospital of the University of Pittsburgh, and co-founder and chief scientific advisor of DenseBreast-info.org.
The FDA’s new changes will require facilities to provide patients with information about breast density and include specific language in mammogram result letters explaining how breast density affects the accuracy of mammograms.
example: Notification “Breast tissue can be dense or non-dense. Dense tissue can make it harder to find breast cancer on a mammogram and increases your risk of developing breast cancer. You have dense breast tissue. Some people with dense tissue may be able to find their cancer by having other imaging tests in addition to a mammogram. Talk to your health care provider about breast density, your risk for breast cancer, and your personal situation.”
Or it could say: “Breast tissue can be either dense or non-dense. Density can make breast cancer harder to detect on a mammogram and can increase your risk of developing breast cancer. Your breast tissue is not dense. Talk to your health care provider about your breast density, your risk for breast cancer, and your personal situation.”
Understanding Breast Density
Berg said mammogram reports list breast density in four categories, ranging from mostly fat to very dense.
In fatty breasts, “it’s very easy to find the cancer, and these women are much less likely to develop breast cancer. The next category is Scattered fibroglandular densities“That’s actually the most common one,” Berg says.
“And in unevenly dense breasts, masses can be hidden, and in this category at least 25 percent of cancers are missed,” she said. “And then extremely dense breasts are the last category where at least 40 percent of cancers are missed. And when you compare women with extremely dense breasts to women with fatty breasts, they are actually four times more likely to develop breast cancer.”
Berg said she determined that, based on her family history and breast density from 10 years ago, she had a 19.7 percent lifetime risk of developing breast cancer, so she urged her doctor to not only get a 3-D mammogram, but also a breast MRI to screen for cancer.
“The MRI showed a tiny invasive cancer that couldn’t be seen on a mammogram,” said Berg, who has since been treated for the disease.
“After this experience, I said, if we’re going to tell women they have dense breasts, there needs to be a place where they can decide if they meet the criteria for an MRI, if they want to get an ultrasound and what they can expect from those tests,” Berg said.
of FDA Note For some people with dense breast tissue, cancer can be detected by using other imaging tests in addition to a mammogram.
“But it doesn’t say anything more than that, and at the end it says, ‘Consult your health care provider,'” Berg said. “The guidelines are not as clear as they should be.”
Many women may not know whether they should request additional imaging tests such as an MRI, and in some cases, their doctor may not deem it necessary. And in some cases, insurance may not cover these options.
“Knowledge is power, and all women can have an informed conversation with their health care provider about the screening plan that’s right for them based on factors that influence their individual breast cancer risk, including breast density,” Molly Guthrie, vice president of policy and advocacy at Susan G. Komen, said in a statement.
“We want people to know that having dense breast tissue alone does not warrant additional imaging – it’s just one factor in breast cancer risk,” added Guthrie. “For people who need imaging beyond a mammogram, out-of-pocket costs are often a barrier, which is why we’ve advocated for state and federal legislation to eliminate these costs. We have the technology to detect breast cancer early and save lives, so financial barriers shouldn’t get in the way. It’s important that people understand what breast imaging they need based on their risk and have access to it at an affordable price.”
The American Cancer Society praised the FDA’s new rules, saying they will reduce diagnostic delays. 1 in 8 women will develop breast cancer In her lifetime.
“The final rule will improve screening by incorporating new technology, better enforcing facility accreditation and quality standards, and enhancing the reporting provided to women and their physicians.” ACS said in a statement. last year.
The ACS said at the time that while the new changes could help reduce breast cancer deaths, more work was needed to ensure all women have access to high-quality mammograms.
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“Black women are more likely to have lower quality screening, which contributes to the continuing disparity in breast cancer mortality rates between black and white women,” the group said.
A study published in 2022 found that breast cancer mortality rates fell by 43% over the 30 years from 1989 to 2020, resulting in 460,000 fewer breast cancer deaths during that period. When the data was broken down by race, black women had a lower incidence of breast cancer than white women, but overall deaths were 40% higher for black women.
“Screening tests are either important or they’re not, and if they are important, they are arguably more important for women who are known to be at high risk and for whom mammograms are a dangerous tool,” Pushkin said. “Informing women about their breast density gives them the opportunity to advocate for themselves. If you don’t have enough information to know that you need to advocate, how can you advocate for yourself?”
