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The 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 dense breasts.


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.

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