Dense Breasts - Do You Need More Screening?

Let me start off by saying, I am not a researcher. I am a physician seeking to offer women evidence-based health information and improved access to healthcare to help them live their best lives.  While I admittedly love shoes and clothes, every Monday evening, I let my nerdy side shine by participating in a live discussion group composed of academic leaders, researchers, and physicians/clinicians devoted to improving women’s healthcare. I soak up the presentations learning from the latest research and how it is applied to clinical practice at leading academic institutions in the US. I take notes, and screenshots of slides and then watch the recorded lecture again while walking on my treadmill (at an incline of course).  The following week I update MymenopauseRx clinical protocols and share my new learning with our clinical team.

Dr Christine E. Edmonds, a radiologist and Assistant Professor of Radiology at the University of Pennsylvania gave a fabulous talk on the radiologic management of dense breasts.  Here I present some breast cancer facts and then dive into how to manage dense breasts since 50% of women in the US will be classified as having dense breasts reported on their mammograms.

First Some Breast Cancer Facts:

• 1 in 8 women will get breast cancer in their lifetime.
  
• Annual breast cancer screening beginning at age 40 saves more lives than delaying screening to age 50.
  
• Yearly mammogram saves lives more frequently than every other year mammogram.  
  
• For every 1000 women who have a screening mammogram, about 100  women will be called back for extra imaging. 19 of those women will need a needle biopsy. Of those 19 women who have a biopsy, 5 will have breast cancer.
  
• The risk of radiation from a mammogram is VERY low and considered insignificant.
  
• White and Black women are more likely than other races to develop breast cancer in their lifetime.
  
• Black women are more likely to develop more aggressive, advanced-stage breast cancer at younger ages and should begin annual mammograms by age 40!
  
  

Now Let’s Talk About Dense Breasts!

What is breast density?  The breasts are made of fat, breast glands, and ducts. When a person is found to have dense breasts, their breasts have more glands and ducts than fat. Your breast density is determined by the radiologist when they are looking at your mammogram films.

Here are the breast density classifications the FDA now requires on every mammogram report:

A - Fatty breasts

B - Average density

C - Dense

D - Extremely dense

Knowing Your Breast Density Is Important For 2 Main Reasons:

1. Dense breasts lower the sensitivity of mammography to detect breast cancer. The more dense your breasts are, the more difficult for the radiologist to pick up small spots on your mammogram that could be an early cancer.
2. Women with extremely dense breasts have twice the risk of breast cancer than women with “average density” breasts.
   
   

Who Needs Supplemental Screening?

So I just told you that having dense breasts increases the risk of breast cancer, which is a fact. Now for the confusion!  There is NO AGREEMENT by the medical societies on what to do about additional testing!

Here is what Dr Edmonds presented-

Women with dense breasts should have their lifetime risk of breast cancer calculated.

If your risk is 20% or higher, a breast MRI is recommended yearly and covered by health insurance.  “MRI Is the Gold Standard for Screening for Breast Cancer”  

If your lifetime risk of breast cancer is less than 20%, you may still qualify for a screening MRI if you have extremely dense breasts - Category D. But each state determines its own rules on what insurance companies are required to cover for supplemental breast cancer screening. It is best to check with your personal health insurance plan before scheduling additional screening tests.

What About Screening Breast Ultrasounds?

Your clinician may recommend a screening breast ultrasound if you are found to have dense breasts (Category C or D). I know I have recommended them in the past but after hearing the data presented by Dr. Edmonds, MyMenopauseRx will no longer do so.  

In summary:

Screening breast ultrasound, both handheld or automated (called ABUS), only detects an additional 2-3 cancers in 1000 women who have them done. Their false positive rate is very high.  Dr. Edmond stated she does not recommend supplement screening breast ultrasound for anyone because there are way too many false positives creating unnecessary callbacks and patient anxiety.  The University of Pennsylvania, where Dr. Edmond is a breast radiologist, does not recommend or perform any screening ultrasounds for dense breasts.  

Know Your Lifetime Risk of Breast Cancer.

I certainly was surprised by this data but am grateful for those who are studying how to better manage breast health.   My advice for those of you with dense breasts - learn your lifetime risk of breast cancer!  Make an appointment with who orders your mammogram and determine a clear breast screening plan based on your personal risk.  Then you can proceed with additional screening that is evidence-based and meaningful to prevent breast cancer. Shared decision-making is good decision-making when it comes to your health.