Dense Breasts

Dense breast tissue causes 2 problems - one is that it is now known that women with dense breast tissue have a higher rate of developing breast cancer, and the second is that breast cancer is harder to detect in women with dense breast tissue. Mammograms will miss 10-20% of breast cancers, more often in women with dense breast tissue. Ultrasound and MRI examinations can be performed in addition to a mammogram, but no test is 100% sensitive and specific for diagnosing breast cancer. Ultrasound and MRI are also more difficult to interpret in women with dense breast tissue, just like mammograms. MRI in particular also has a relatively high (up to 20%) false positive rate - it will often show things that look suspicious and require further investigation and sometimes biopsy, and the finding then turns out to be normal - these are some of the reasons that MRI is not recommended as a general screening test for all women, but rather is recommended for use in specific situations.

I do feel that women should know their breast density - "lumpiness" on exam is not the same as dense breast tissue. This information is generally included in the formal mammogram report provided to the ordering physician, but is not required to be included in the "lay letter" - the letter that gets sent to the patient (the wording of the reports and the lay letter is regulated by the FDA under the Mammography Quality Standards Act: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Regulations/ucm110906.htm#s9004

Connecticut and Rhode Island have passed legislation requiring that the patient be informed of her breast density, and this is pending in California as well.

There are no uniform recommendations for how to provide increased screening to women with dense breast tissue, but at the very least, make sure that when you get your mammogram, you get a newer digital mammogram, rather than an older, film-screen - you just need to ask the facility and they will let you know. The use of ultrasound and MRI should be discussed with your physician or breast specialist and will take into account your family history and other breast cancer risk factors as well as breast density.

As usual, Dr. Attai you have a great answer. Question: How do we get other states to get on board with legislation requiring the patient to be informed of her breast density? Would you know?

My gynecologist(s)- I've had a number NEVER told me that because I had dense breasts I should have further testing beyond a mammogram, and the ultrasound (my decision to get one) was what picked up the cancer, NOT the mammogram. Obviously this is upsetting because my cancer could have been picked up at stage 1 instead of stage 4. The difference between life and death, literallly.

Breast density is something that we as radiologists are always aware of. We always mention in our mammography reports whether the breasts are very dense, moderately so, or not very dense. There are actually 4 categories. The problem is that the information is not always communicated to the patients. We are required by MQSA to provide every patient with the results of their mammogram in writing. Some folks mail these results while others, like myself, usually provide it to the patient when she has completed her exam. We are now attempting to include information about density in those results. Our mammography technologists will answer any questions that the patient may have, and frequently I will also speak with them myself. I don't really have an opinion about whether legislation is the way to handle this.

In women who have very dense tissue I recommend that they have ultrasound of their breasts every year, as well as a mammogram. The two tests are complementary and give slightly different information. But the basic difference is that in mammography everything is compressed and therefore superimposed. With ultrasound the beam can show everything from the front of the breast to the back. In my experience most insurance companies reimburse something for breast ultrasound if the patient has dense breast tissue.

First, to clarify, I am NOT an MD or a clinician, I am a PhD and my area of expertise is in cancer biology. That being said, there are several different methods, in addition to mammography, that can be used to screen for breast cancer.
1. Ultrasound- Ultrasound is the use of high frequency sound waves that 'bounce' off of internal structures and can provide a picture of the inside of a breast.
2. Elastography- This is a variant of ultrasound in which two different images are obtained. The breast is imaged in the normal way and is then re-imaged while it is being compressed (squashed). The idea behind this is that normal breast tissue will easily squash down but cancers are hard and do not change shape when the breast is flattened out. When the two images are compared, areas can be identified that failed to flatten out.
3. Breast MRI-Magnetic resonance imaging uses a strong magnet to alter the properties of the water in the tissue being examined (breast tissue in this case) to create an image of the breast.

If any of the methods above lead to the suspicion of cancer, a biopsy can be performed to determine if cancer is present. Note that NO medical test is perfect and it is important to understand the limitations of the tests (see below).

Learn more about cancer detection and diagnosis methods on the CancerQuest website: http://www.cancerquest.org/cancer-detection-diagnosis. Videos are also available about medical testing.

I just wanted to chime in and attest to what Dr. Radford is saying from the patient/anecdotal perspective. I have dense breast tissue. After 12 years of faithfully getting annual film mammograms, my first-ever digital mammogram captured the specks that turned out to be DCIS. And I had a lot of it; two attempts at breast-conserving surgery couldn't get the clean margins my doctors and I were hoping for, so I opted for a mastectomy. I wonder if it might not have been caught sooner if we had used digital mammograms earlier. I had a digital mammogram simply because the radiology group my clinic uses switched to that technology; a nurse told me that they noticed a huge jump in breast cancers after they started using it.

After it was confirmed I had DCIS my oncologist also ordered an MRI to make sure we weren't missing something, and he said he may recommend the occasional MRI going forward (I only had a single mastectomy so we're keeping an eye on the other breast.)