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The confusion about breast density

Since the passage of Henda’s Law, thousands of women across Texas have received notification from their doctor’s office about “dense breast tissue” possibly impeding the results of their mammogram.   The notifications have caused confusion and concern for many women.  Certified Menopause Specialist with The Austin Diagnostic Clinic (ADC)   Michele McDermott, MD and Breast Imager with Austin Radiological Association (ARA) Catherine Young, JD, MD worked together to provide this comprehensive question and answer guide for women concerned about breast density, mammograms and what it all means.

Michele McDermott, MD, ADC Certified Menopause Specialist

Michele McDermott, MD, ADC Certified Menopause Specialist

Catherine Young, MD, ARA Breast Imager

Catherine Young, MD, ARA Breast Imager

What is Henda’s Law?

Henda’s Law is a bill that was passed by the Texas House and Senate in 2011 that was named after Henda Salmeron, a woman who found a lump in her breast that had not been detected on her mammogram. The lump turned out to be a large malignancy in her breast, missed because Henda had dense breast tissue.

Henda’s Law requires that mammography providers notify all women with dense breast tissue that the accuracy of their mammograms is less than that of women with lower breast density, and that they may benefit from “supplemental screening” in addition to their annual mammogram.  www.texashealth.org/hendaslaw

The Austin Diagnostic Clinic Women’s Imaging Center sends a letter to inform a woman of her mammogram result. The letter includes a comment to inform the woman if she is found to have dense breast tissue.

How common is having dense breasts?

40% of women have dense breast tissue and 10% of women have extremely dense breasts.

Why does it matter if I have dense breasts?

Your breasts are considered to be dense if you have a lot of fibrous or glandular tissue, but not much fat. Breast density is a well-established predictor of breast cancer risk.

Dense breasts also make it more difficult for the radiologist to detect cancer on a mammogram. Dense tissue appears white on a mammogram. Lumps also appear white, so they can be very difficult to see. Mammograms can be less accurate in women with dense breasts.

Women with dense breasts have a four-to-six fold increased risk of developing breast cancer.

What other things may affect breast density? Is it dependent on the size or feel of my breasts?

Use of menopausal hormones may increase breast density. Breast density is not related to breast size or firmness and can only be identified on a mammogram.

If I do breast self-exams, how would I tell the difference between fibrous tissue and a lump?

Fibrous tissue can sometimes feel like a lump in the breast. To determine if you have a breast lump a mammogram should be performed. Other imaging tests such as breast ultrasound may also be used to evaluate lumps felt on a breast self-exam.

Am I at higher risk for breast cancer due to my menopause?

Breast cancer risk increases as women age, and the chance of being diagnosed with breast cancer is higher after age 50. If you choose to take menopausal hormone therapy, your risk for breast cancer may be increased.

What can I do to lower my risk for breast cancer?

Make healthy lifestyle choices that may reduce your risk of breast cancer, such as:

  • Maintain a healthy weight
  • Add exercise into your routine
  • Limit alcohol intake
  • Limit postmenopausal hormone use
  • Breastfeed, if you can

My breasts are lumpy and/or firm.  Does this mean that I have dense breasts?

No.  Breast density refers to the appearance of the breasts on a mammogram rather than to breast size and/or firmness.  Some breasts that feel firm are not dense on a mammogram, and vice versa.

What makes breasts dense on a mammogram?

Breasts are made up of variable amounts of fatty and fibroglandular tissues.  Fibroglandular tissue is denser than fatty tissue.  This corresponds to the whiter areas on a mammogram.  If a woman has a lot of the denser fibroglandular breast tissue and not much fatty tissue, then her breasts are considered dense. It is not abnormal to have dense breasts.

Breast Density

Breast Density mammogram image, courtesy Dr. Catherine Young, ARA

How is breast density measured on a mammogram?

The radiologist reading the mammogram visually assesses the density, placing it into one of four categories (shown above):

  • Almost entirely fat
  • Scattered fibroglandular
  • Heterogeneously dense
  • Extremely dense.

Very recently, the definitions for each category have been revised.  As a result of these changes, more breasts will now be considered dense.

Why does breast density matter when viewing a mammogram?

  • It matters mainly because it is more difficult to see cancer on a mammogram if the breasts are dense. On a mammogram, most breast cancers appear as a white “spot.”  Normal fibroglandular tissue is also white.  If the breasts are dense (have lots of fibroglandular tissue), then small cancers can be masked or hidden. Note how it becomes harder to see the asterisks at the bottom of the above illustration as the background becomes lighter.  This is why looking for breast cancer on a mammogram has been compared to looking for a snowman in a snowstorm.
  • Having dense breasts is also one of many factors contributing to overall breast cancer risk. Other important risk factors include: age, menstrual history, pregnancy history, personal/family history of breast cancer, obesity, and alcohol use.

How can I find out if my breasts are dense?

Texas law requires you to be notified if your breast tissue is considered dense in the letter containing the results of your mammogram.  Usually, there will be a statement in the letter along the lines of “your breasts are considered dense.” A description of breast density is also included in the actual mammogram report that is sent to your doctor.

I am confused.  Last year my mammogram letter said that my breasts were not dense.  This year my letter says that they are dense.  Did my density really change?

You are not alone in your confusion.

Breast density tends to gradually decrease with age, but can change from year to year, usually in association with hormonal changes:

  • Lactation increases breast density until a woman stops breast feeding.
  • Bilateral oophorectomy (surgical removal of both ovaries) typically results in decreased breast density.
  • Hormone replacement therapy or changing an existing regimen commonly affects breast density.
  • Breast cancer medications may decrease breast density by blocking the effects of hormones normally produced by the body.
  • Substantial changes in weight affect density by altering the amount of fatty tissue in the breast.
  • If the breasts are not well compressed for the mammogram, they may seem to be denser than they really are.

Keep in mind, however, that recent changes to the way breast density categories are defined means that some breasts previously categorized as “not dense” are now being considered “dense.”  Individual radiologists may also differ in their perception or assessment of density.

My breasts are dense.  Should I still get a mammogram?

Yes!  Most breast cancers can be detected by mammography even if the breasts are dense.  It is the one breast imaging test proven to save lives.  Ductal carcinoma in situ (an early form of breast cancer) is often seen only by mammography.

Are digital mammograms better for women with dense breasts?

Yes.  It is easier for the radiologist to “see through” dense breast tissue on a digital mammogram compared to old film-screen mammograms.  Most mammograms performed in the U.S. today are digital.

What is a 3D mammogram?

3D mammography (also known as digital breast tomosynthesis) is a new technique where the x-ray tube moves as the mammogram is acquired so that the breast is imaged at a greater number of angles.  This reduces the amount of tissue overlap on the mammogram, which can be especially helpful in dense breasts.  Because a 3D mammogram is currently performed in addition to the regular 2D mammogram, the amount of radiation is increased (but is still less than the radiation associated with old film-screen mammograms).  3D mammograms are more expensive, and until very recently, the extra cost was not covered by insurance.  3D mammograms are becoming more widely available and may ultimately replace most 2D mammograms.

My annual mammogram was normal.  Should I be getting any additional tests to screen for breast cancer?  Does the answer depend on whether my breasts are dense?

Annual mammography is the only screening test currently recommended for women at average risk for breast cancer (lifetime risk of 12-13%).  This is true regardless of breast density.

 How can I determine my risk for breast cancer?

  • Discuss your breast cancer risk factors with your physician who can then use one or more well-validated models or “tools” to estimate your risk. It is important to understand that no physician or tool can determine which women will actually develop breast cancer.
  • You may want to start with the free online calculator at http://www.cancer.gov/bcrisktool. Depending upon your specific personal and family history, however, other tools might be better at estimating your risk.  The quiz at http://www.brightpink.org/knowledge-is-power/assess-your-risk may help you determine if this is the case.
  • Women at high risk for breast cancer (lifetime risk of 20% or greater) are recommended to have annual breast MRI in addition to a mammogram.
  • Women at moderate risk (lifetime risk greater than average, but less than 20%) should discuss the pros and cons of supplemental screening with their doctors in order to make informed decisions based on their individual situations.

My risk for breast cancer is greater than average.  Other than my annual mammogram, what other tests should I consider?

  • Women at high risk for breast cancer (lifetime risk of 20% or greater) are recommended to have annual breast MRI in addition to a mammogram.
  • Women at moderate risk (lifetime risk greater than average, but less than 20%) should discuss the pros and cons of supplemental screening with their doctors in order to make informed decisions based on their individual situations.

My risk for breast cancer is average, but my breasts are dense.  Should I have screening breast ultrasound or MRI (supplemental screening) in addition to my mammogram?

This is currently a subject of much debate. You should weigh the relative risks and benefits of supplemental screening with your doctor before deciding whether it is right for you. Some points to keep in mind:

  • Annual mammography is the only test recommended for women of average risk (regardless of whether the breasts are dense)
  • While ultrasound and MRI can detect small cancers that are not seen on a mammogram, they are more likely to identify findings that are not cancer. Several studies have reported that 95-97% of biopsies recommended for screening ultrasound findings do not show breast cancer.  This means that for every 100 women biopsied, only 3-5 actually have breast cancer.
  • Insurance may not cover the cost of a screening breast ultrasound or MRI for women at average risk for breast cancer. However, insurance should cover any further testing or biopsy recommended as a result of a screening ultrasound or MRI.
  • Screening breast ultrasound and/or MRI should be covered for women at high risk for breast cancer.
  • Although not required to do so by law, many insurers will pay for a woman with dense breasts to get a screening breast ultrasound even if she is not otherwise at increased risk for breast cancer – check with your insurance carrier to see whether they provide this coverage or not.
  • When breast ultrasound is recommended by your doctor or radiologist to evaluate a specific problem or mammogram abnormality, the exam should be covered.
  • When breast MRI is recommended by your doctor or radiologist to evaluate a specific problem or mammogram abnormality, the exam may be covered – most facilities will verify coverage with your insurer prior to performing breast MRI.

My annual mammogram is covered by insurance.  Are breast ultrasound and MRI covered by insurance?

  • Screening breast ultrasound and/or MRI should be covered for women at high risk for breast cancer.
  • Although not required to do so by law, many insurers will pay for a woman with dense breasts to get a screening breast ultrasound even if she is not otherwise at increased risk for breast cancer – check with your insurance carrier to see whether they provide this coverage or not.
  • When breast ultrasound is recommended by your doctor or radiologist to evaluate a specific problem or mammogram abnormality, the exam should be covered.
  • When breast MRI is recommended by your doctor or radiologist to evaluate a specific problem or mammogram abnormality, the exam may be covered – most facilities will verify coverage with your insurer prior to performing breast MRI.

About The Austin Diagnostic Clinic

The Austin Diagnostic Clinic (ADC) has cared for Central Texans since 1952.   We are an independent group of 125 doctors, practicing in 21 medical specialties at 9 locations throughout Austin and Central Texas.  We strive to provide compassionate care and excellent service for every patient we serve.  To learn more about our doctors, specialties or locations visit ADClinic.com.

About Austin Radiological Association

Since 1954, Austin Radiological Association (ARA) has been a leader in imaging services in Austin and Central Texas, providing CT, MRI, mammography, MBI, x-ray, ultrasound, PET/CT, SPECT/CT, nuclear imaging and bone densitometry. For 60 years, ARA has committed itself to innovation and invests in the latest technology to provide the highest quality of care to patients and referring physicians. Find out more about ARA by visiting ausrad.com.

Comments

  1. Anonymous says:

    Thank You!!! Very helpful!!!

  2. Anonymous says:

    Thanks for the info. I learned lots.

  3. Anonymous says:

    This was better than the statement that came in my mammogram results letter.

  4. Anonymous says:

    I got a mammogram in Nov in Austin.. Just got the report today that they need to have another mammogram and a sonogram… never got a letter from the doctor… Now I no longer have insurance… Any clinics in Austin that would help me… thanks

    Here is some information about no and low cost mammography programs for women in Austin and Williamson County.

    Low cost and free mammogram eligibility varies with county of residence, age, income, insurance status and whether or not you have symptoms.

    For residents of Austin or Travis County:

    Women’s Wellness Center of the University of Texas School of Nursing
    512-232-3900
    Seton Cancer Screening Program
    512-505-5528 or 866-294-4923
    For residents of Williamson County:

    Community Health Services Clinics
    Taylor: 512-352-7697
    Round Rock: 512-248-3256
    Cedar Park: 512-260-4243
    Georgetown: 512-930-3280
    Williamson County Medical Assistance/Social Services: 512-248-3252