What women–and their physicians–need to know about breast density

Breast density has received national attention from the New York and California density inform bills going into effect and the passage of the Hawaii, Maryland, Tennessee and Alabama bills.  With significant coverage of studies evaluating the impact of dense breast tissue on cancer screening, it seems that breast density is in the news nearly every day. 

Controversial or not, it is clear that density notification is rapidly moving forward: nine states have passed laws (CT, TX, NY, VA, CA, MD, HI, TN and AL), 20 states have pending legislation and the federal Breast Density and Mammography Reporting Act of 2011 is also in progress.

Even if you don’t practice in a state that requires physicians to inform women of their breast density, it is becoming an important women’s health topic. 

Helping women understand breast density

As a dedicated breast imager, I recognize the need to build awareness about the role breast density plays in the screening environment and fully support enabling women with information to help them have knowledgeable conversations with their doctors and make individualized healthcare decisions. 

First, it is important to reinforce that mammography remains the gold standard for the early detection of breast cancer and all women should get regular mammograms as recommended by their doctor.

If women have been informed that they have dense breast tissue, they should talk to their doctor about their specific risk and additional screening tests that might be appropriate.  This may include automated breast ultrasound (ABUS), which has been proven to increase cancer detection by 35.7 percent in women with dense breasts and no prior breast interventions.

It’s important to ensure that women–and their physicians–understand that having higher breast density is normal and DOES NOT mean:

1. That they already have breast cancer;
2. That they are guaranteed to get breast cancer.

However, understanding breast density is important to maintaining breast health because dense breast tissue DOES:

1. Reduce the sensitivity of mammography and can mask cancer. Mammography is likely to detect cancer in a fatty breast in most cases; however, as density increases, the likelihood of a cancer being detected is reduced.
2. Increase a woman’s risk of breast cancer.  Research has proven that breast density has a direct correlation to cancer. According to the Boyd et al study published in the New England Journal of Medicine (2007; 356: 227-36), women with very dense breasts are up to 4-6 times more likely to develop cancer than women with fatty breasts.

Proactive breast density outreach and education

Ultimately, the goal is to educate women in your community about breast density to ensure they understand their risk and what options they have for taking control of their health. However, because many primary care physicians are not well versed in breast density, you will likely need to start your education efforts with them. 

Most breast centers have very strong outreach capabilities and regularly promote the availability of new technology (digital mammo, breast MR, ABUS, etc).  Even if you’re not facing density inform legislation in your area, I encourage you to leverage this strength and proactively promote breast density awareness.  

You probably have density information on your website or have links to content from advocacy organizations. However, if you haven’t already conducted outreach to physicians in your area regarding breast density, I encourage you to proactively explain breast density and its impact on mammography screening, and which supplemental imaging tests may be appropriate for their patients with high density.  

Arm your staff with resources to address patient concerns

Patient anxiety is often identified as a rationale for opposing breast density notification.  However, after talking to patients about breast density for years, I have never had a woman experience undue anxiety.

To deliver this important breast health information in an efficient manner and reduce potential anxiety, it is important to ensure that the staff is trained to give a consistent, positive message.

Training the mammography technologists or nurse navigators on how to explain breast density, to reinforce that it is perfectly normal, and that there are tools to evaluate her breast health further is crucial.  o align the entire staff around the right message, I encourage you to develop a script and FAQs as well as guidelines on how to address patient concerns and when to offer the woman a consultation with a radiologist.   

Informed patients make better choices

While the debate over breast density may continue for some time, it is clear that women want information that enables them to make intelligent choices and take charge of their breast health.  In the long run, an informed patient population that is motivated to comply with the best possible screening program, can only improve our efforts to find cancer early when it most treatable.

There has been some opposition to density inform legislation because some radiologists are concerned that there are too many holes in the system. I encourage breast imagers to lead the process to improve breast density awareness and standardize the breast screening process. 

About the author: Jessie Jacob, MD, a board-certified and fellowship-trained, dedicated breast imager, is the Director of Ultrasound for the Northern California Women's Imaging Center in Palo Alto, Calif., and recently joined U-Systems, a GE Healthcare Company, as Vice President of Medical Affairs. Previously, Dr. Jacob directed breast centers in California and New York.