Current Debate on Breast Density
By William Carroll, MD, PhD
There is a national debate about whether or not women should be
notified directly if there is a finding of “dense breasts” on their mammogram.
This issue is generating quite a bit of discussion not only among physicians
but among state and federal legislators, as well.
What does the term “breast density” mean?
The composition of normal breast tissue varies widely among women,
ranging from breasts that are less dense and composed almost entirely of fatty
tissue to breasts that are quite dense with significantly more fibroglandular
tissue and less fat. A finding of high breast density on a mammogram is not
abnormal; rather it is a normal variant.
Why is breast density important?
Breast density is important because there is a general (although
not universal) consensus among health care professionals that the risk of
breast cancer may be as much as four times higher among patients with high
breast density as compared to those with low breast density. Density is also
important because the sensitivity of a mammogram is decreased in women with
What is the basis for the debate on breast density notification?
In 2009, a 59-year-old Connecticut woman was found to have a
palpable mass in her breast during a visit to her doctor. The mass, which
proved to represent advanced breast cancer, was not identified on a mammogram
performed six weeks earlier. The patient stated that if she had known she had
dense breasts she would have had an ultrasound because she believed that an
ultrasound would have led to an earlier cancer diagnosis. She took her story to
the state legislature and, as a result, Connecticut was the first state to
mandate laws requiring disclosure of breast density directly to the patient. New
York State passed a similar law that went into effect in January 2013.
What does this mean for patients?
Federal regulations require that radiologists send a notification
letter to patients following their mammograms. In order to be in compliance in
New York State, this letter now includes the following excerpt:
"Your mammogram shows that your breast tissue is dense.
Dense breast tissue is very common and is not abnormal. However, dense breast
tissue can make it harder to find cancer on a mammogram and may also be
associated with an increased risk of breast cancer. This information about the
result of your mammogram is given to you to raise your awareness. Use this
information to talk to your doctor about your own risks for breast cancer. At
that time, ask your doctor if more screening tests might be useful, based on
your risk. A report of your results was sent to your physician."
What is the controversy?
Not all groups are in agreement as to the value of direct patient
notification of breast density. In addition, some medical professionals and
medical societies have raised concerns about the potential of unintended
consequences of this legal mandate. Chief among their concerns are that this
legislation may lead to further unnecessary tests and treatments, and that this
additional testing may not be covered by insurance carriers. Caregivers also
worry that direct notification may lead to further patient anxiety that could
be avoided with a conversation between the patient and her doctor. Furthermore
while the Connecticut experience shows that more cancers have been detected,
there has also been an increase in the false positive rate and an increase in
the total number of biopsies.
What are your recommendations?
My colleagues and I encourage patients to be active participants
in their own care. Regardless of breast density, women still need yearly
mammograms beginning at age 40. We also encourage women with dense breasts
to discuss with their doctor whether additional screening exams are required.
William Carroll, MD, PhD, is a board certified radiologist on
staff at Cayuga Medical Center, where he is director of mammography. He may be
reached by calling 607-274-4011.