A healthy lifestyle means knowing a few things about your body – even if you’d rather ignore those facts. Weight, cholesterol readings, hormonal cycles, and osteoporosis risk are starting points for many women. Now you can add something else to the list – breast density.
Density refers to the amount of fibroglandular tissue (tissue besides fat or muscle, including milk ducts and lobules, connective tissue, etc.) in the breast. On a mammogram (which looks like an x-ray to the untrained eye), dense tissue appears white and opaque, while the fatty tissue appears black.
The problem is that breast tumors or benign masses also appear white on the mammogram. So, for radiologists, searching for very small lesions in dense breasts is like looking for a snowman in a blizzard. Most women don’t know what type of tissue they have, and therefore don’t have enough information to start a conversation with their doctors.
A new law in New York changes everything. As of Jan. 19, 2013, providers are required to notify women if more than 50 percent of their breast tissue is dense. To learn more about why this is important, we spoke with Dr. Avice O’Connell, director of Women’s Imaging at the University of Rochester Medical Center and Highland Breast Imaging.
Scripts: It seems that many women might not realize that density is an issue in breast health. Is this true, in your experience?
O’Connell: Yes, absolutely. I see many women who are not familiar with their own breasts. They may not do monthly self-breast exams, and they often don’t ask questions during their routine mammograms. Awareness of breast density is low. However, later, if women do find out that they have very dense tissue, they’ll say, ‘if I only had known this.’ The new law gives women more information – and in my opinion, more information is usually a good thing.
O’Connell: We’re not sure why some people have dense breasts. You can’t tell from the outside. In other words, it’s not related to a person’s size, age, or any other characteristic. We do know that density tends to ebb slightly with age (50s and post-menopause) – but only a mammogram can give us that information.
Scripts: Why is dense breast tissue a health hazard?
O’Connell: It’s a problem for two main reasons. First and foremost, small cancers can hide more easily in dense tissue. And simply having dense breasts slightly increases the risk of cancer.
The latter issue, however, is still being investigated and the risk is slight. In general we still have many questions about the impact of breast density on breast health. But from a practical standpoint as a radiologist who reviews thousands of films a year, I can say with certainty that detecting breast cancer in dense tissue is more difficult. A cancerous mass appears white and can be obscured by the white dense breast tissue and the spidery-looking fibrous glands surrounding it.
O’Connell: When a woman gets a routine, screening mammogram and we find no problems – other than dense breast tissue – she’ll receive a letter in a few days notifying her that her tissue is dense. The law’s intention is to boost awareness, not necessarily to prompt more testing. At that point, most healthy women with few or no risk factors for cancer will choose to do nothing. Radiologists are not required to make any recommendations on testing, either.
However, if you get one of those letters, we’re urging women to talk to their primary care physician or ob/gyn about their personal risk for breast cancer. Discuss family history, start of menstruation and early menopause (an early start and late finish are both risk factors), childbirth (if you’re older with your first pregnancy, that’s also a risk factor), and lifestyle habits such as overeating and excessive drinking. Based on an assessment of your personal risk for breast cancer, coupled with your dense breasts, your physician may recommend supplemental testing with a screening ultrasound or an MRI.
But this isn’t a simple decision, or a perfect solution. Sometimes an ultrasound opens a Pandora’s Box. Plus, additional testing takes time and money. The law doesn’t require insurance to cover screening breast ultrasounds, but most insurers have indicated they’ll pay for it with a physician’s referral.
Scripts: By ‘Pandora’s Box,’ you must mean that more information will cause needless worry for some women, correct?
O’Connell: Yes. The main drawback is that the more ultrasounds we do, the greater likelihood of finding small, solid masses that need to be biopsied and followed up. More than 90 percent of the time they will turn out to be benign. But an ultrasound provides a different view of the breast tissue, and studies show that ultrasounds will detect about three more cancers per thousand patients with an otherwise normal mammogram. And when cancer is detected earlier, it’s often more treatable. So, I like to say: “A little worry is better than a little cancer.”
Avice O’Connell, M.D., has practiced radiology for over 30 years in Rochester, New York. To contact Dr. O’Connell or to make an appointment at University Breast Imaging, please call 585-334-5519. Locations include 500 Red Creek Drive, Suite 130, in Henrietta; and Highland Breast Imaging at Highland Hospital, 1000 South Ave., Rochester
To learn more about good breast health and protective breast screening exams, watch Dr. O’Connell in this video clip, produced by URMC-based Peri-FACTS Academy, a multimedia continuing education program for OB/GYN healthcare providers.