Breast density: we can handle the truth - InSight+

Breast density: we can handle the truth – InSight+

NOT telling women about their dense breasts is robbing them of the opportunity to seek additional breast cancer screening and the chance to catch any cancer early, experts say.

In reaction to recent InSight+ article, who questioned whether breast density reporting should be routine practice in Australia, Professor Wendie Berg, a professor of radiology at the University of Pittsburgh School of Medicine, said women “need to know the truth”.

“Women can handle the truth,” she said InSight+ in exclusive podcast. “Mammography has limitations, and we know that for women with dense breasts [mammograms] misses 40% of cancer cases. They just don’t show up.

“Women need to know the truth. And when they know the truth, they can gain the power to seek further screening.

“It’s up to the medical community to educate themselves and develop these options to help improve cancer detection.”

In the US, 38 states now require mammography services and radiologists to provide women with some level of information about breast density after their mammogram. Mammograms are free for women over 40 and are recommended once a year.

Ms. JoAnn Pushkin, who co-founded with Professor Berg as a resource for patients and physicians, said InSight+ there was no room for a paternalistic approach of “trying to protect women from the anxiety of knowing they have large breasts”.

“I went for a mammogram every year and every year I got a normal result,” she said.

“One day, during a self-examination, I felt a lump. I wasn’t particularly worried because I had recently had a normal mammogram. But I called my doctor and they called me in for a diagnostic mammogram, and even though the lump was so big I could feel it, it didn’t show up on the mammogram,” she said.

“When I asked why it was missing, the technologist said ‘oh dear, you have thick breasts – that’s going to be hard for us to find’.

“I found out I had breast cancer, and I found out I missed it because I had dense tissue, and I found out I had dense breasts, all in the space of 5 minutes.

“If only I understood the cloaking effect. [of dense breasts on a mammogram]I would definitely ask if there is another tool after the mammogram that we should be talking about.

“Not being told this information effectively denied me the opportunity to have this conversation and denied me the opportunity for an early diagnosis. You can’t talk about something you don’t know you should be talking about.”

Ms Pushkin said the argument to protect women from the anxiety of additional or “unnecessary” testing was “ridiculous”.

“I’m someone who would happily take the temporary anxiety of further testing to know that I have cancer and that I caught it early,” she said.

“When we talk about unnecessary testing, let’s be clear that additional testing will either detect cancer or not. Are we saying that any medical procedure or test that does not result in an abnormal finding is unnecessary? How ridiculous.”

Women who know they have dense breasts may consider additional screening through magnetic resonance imaging (MRI) in addition to or instead of mammograms, Professor Berg said.

“Dense breasts are a double whammy,” she said.

“They increase the risk of breast cancer because most of this dense tissue is glandular tissue.” The more glandular tissue there is, the more cells divide and potentially respond to estrogen, and the more they can make mistakes and develop into cancer.

“Absolute risk [of developing breast cancer] it is actually about four times higher in extremely dense compared to fatty breasts.

“About 10% of women have fatty breasts, about 40% of women have diffuse fibroglandular density, another 40% have heterogeneously dense breasts and about 10% have extremely dense breasts,” Professor Berg said. InSight+.

“About 40% of all women who have a mammogram have dense breasts. So it’s a common problem.”

One pushback from US providers was the fear that they would be overwhelmed by the large number of women who wanted additional screening.

“The enemy of good is perfect,” said Professor Berg. “Not every woman wants to seek additional screening, but if she actually wants to do it and is willing to jump through a few hoops to get it, she might benefit from it.”

Another major barrier is the lack of awareness among doctors about dense breasts and the implications for breast cancer risk.

A breast cancer survivor with dense breasts, Professor Berg said her own experience opened her eyes to the education that was needed for her colleagues.

“I had a family history of breast cancer. We had a recommendation recommending that women get an MRI if they had an increased lifetime risk of about 20%. My own risk was 19.7%, so I said I’d go for an MRI,” she said.

“I’ve already been educating my own doctor about additional screening because I led the study and found great results, especially with MRI.

“My own doctor, when I said I’d like to get a script for an MRI, said, ‘tell me again why you want it’. I just spent a good hour plus sending him all these papers, my own papers, studies, telling him how to calculate risk and he didn’t understand.

“We have to educate women directly because you can’t just send them back to their doctors if their doctors don’t know.”

“Long story short, I got an MRI and found my own cancer. It was early and small and easily treated.

“At the end of the day, every woman wants to be screened for breast cancer early. She wants to know that the test she is taking will actually give her an accurate result.

“And unfortunately, we know that mammograms don’t do very well in women with dense breasts.”

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