Some Women Need More Than A Mammogram - Do You?
June is upon us and in my home state of Michigan and this year it means more than the start of our three short months of summer. New legislation took place June 1st mandating that patients be notified if they have dense breasts on mammograms. This has created a whirlwind of confusion as to what exactly to do with this revelation to countless women. Are they at greater risk for breast cancer? What testing should be done beyond mammograms? Will this be covered by insurance? Michigan is not alone in these confusing considerations regarding our current standing in breast cancer prevention. This blog will attempt to bring clarity to the situation for the individual navigating through breast cancer screening.
"Why Does Density Matter?"
Breasts, given their function, are not uniform. Beneath the skin, they are made up of multiple glands tasked with producing milk during lactation as well as fatty tissue and fibrous tissue. X-ray pictures of the breasts as performed with a mammogram aim at looking beyond the gland and fatty tissue and identifying the tell-tale red flags of breast cancer. These may be a mass that does not look like typical breast tissue or more insidiously calcium deposits in a characteristic pattern.
Dense breast tissue appears more white on mammography. Masses and calcifications also appear with increased density/whiteness on X-ray. This makes it more difficult to evaluate for small masses and calcium deposits.
While women with increased breast density have only a slightly increased risk for breast cancer, they are at increased risk for inaccurate cancer detection. It is more an issue of a reduction in the effectiveness of a mammogram alone in detecting breast cancer in its early stages.
"How Dense Is Too Dense for a Good Mammogram?"
Evaluation of a mammogram is quite methodical. Most centers incorporate computer-aided detection to help a radiologist identify abnormalities. Breast density is evaluated as follows:
Breast Imaging Reporting and Data Systems (BIRADS) Classification:
A: The breasts are almost entirely fat
B: There are scattered areas of fibrous-glandular density
C: The breasts are heterogeneously dense, which may obscure small masses
D: The breasts are extremely dense, which lowers the sensitivity of mammography
Essentially, the dense categories are BIRADS categories C and D. While the increase in risk with C is negligible, progression to D yields a small increase in risk.
"Are Their Other Options Besides Mammogram?"
Accuracy of breast cancer detection is increased beyond mammography with two different tests offered as an adjunct. 3-D tomosynthesis is like a mammogram with the exception that it is in three different dimensions. This creates a picture that allows the radiologist to look at all areas from different angles amidst the increase in density. An MRI looks at fine virtual slices of the tissue in images that show more that the simple black and white of X-ray images.
While it would be nice to just perform these tests on every woman to eliminate the limitations of density, there are presently the prohibitive factors of cost and availability. As such, considerations must be taken as to who should have the next level of testing.
"Should Women with Dense Breasts Be Worried?"
If you find out that you have dense breasts based on a mammogram report do not be alarmed. This is extremely common. Don't run out and request tomosynthesis or an MRI just yet if you have dense breasts on your mammogram. While breast density is a consideration, the most important factor is risk. The addition of dense breasts to significantly increased risk should be evaluated more accurately. Increased risk can be determined by a family history of breast cancer, a personal history of breast and other more minor factors.
Increased breast density of BIRADS C or D should simply prompt a discussion with your doctor to determine breast cancer risk and whether further testing is warranted.
"What Steps Should I Take?"
Don't forget to get your mammogram yearly, starting at age 40. Also, perform self breast exams routinely. This should be performed around six days after the period. Menstruation can make the breasts tender and change the consistency so using the menstrual cycle as a guide until menopause rather than the calendar is a better idea. After menopause, going by the same day of the month is fine. Remember, routine self exam makes you an expert of your breast landscape so that change will be apparent.