Are you dense? What every woman and her healthcare provider needs to know.

courtesy: Are you dense

Nearly 20 plus years of research have provided sufficient evidence to link dense breast tissue and increased risk of missing cancer diagnosis by screening mammography. As the breast density increases, the reliability of mammogram as a screening tool for picking up breast malignancy decreases.

What is meant by “being dense”? Breast density does not correlate with physically palpated firmness of breast, it is a radiologic finding and cannot be predicted without obtaining a mammogram. 

Mammographic breast density is defined as the relative amount of radio-opaque (white) elements to radiolucent (black) fat on the image. Increase in the proportion of radio-opaque elements leads to greater mammographic breast density.

Radiologists find it difficult to distinguish between tumor and normal dense tissue, both of which appear white on a mammogram.

In fact, mammography will only detect 30% cancer in dense breasts and 80% in non-dense breasts.

Nearly 40% of women have dense breast, which means that only using mammography as a screening tool puts this population at high risk of missing the diagnosis, delayed diagnosis or diagnosis at very late stage of disease. A recent search of PubMed revealed nearly 3,027 studies on masking risk of dense breast tissue.

Increased density of breast is a casual as well as masking risk factor for breast cancer. According to the American Cancer Society, having heterogeneously or extremely dense breast tissue puts you at risk of breast cancer that is equivalent having one first-degree relative with breast cancer. (2.1 to 4 times the normal risk)

Also, women with dense breast are put at increased risk of developing contralateral breast cancer and interval cancer (cancer detected within 12 months of a normal mammogram)

A recent Breast Cancer Surveillance Consortium study noted that breast density exceeds all other risk factors like obesity, family history and delayed childbirth.

About 28 states in USA have passed law regarding the mandatory reporting of breast density and the necessary follow up thereafter, after women have a screening mammogram.

So, is there a standard protocol for supplemental screening if a woman is diagnosed of having dense breast on screening mammogram? No, unfortunately not, the medical community has not agreed on a protocol regarding supplemental screening for women with dense breasts.

In a position statement, the ACOG, identifies dense breast as a moderate risk factor but does not support routine use of adjunct screening modalities in an average risk woman with dense breast. The American Cancer Society urges the patients with dense breast to talk to healthcare providers about additional screening modalities and advises an MRI along with her yearly mammogram in a high-risk group.

The American College of Radiology identifies breast density as a controversial risk factor for breast cancer with no consensus that it confers sufficient risk to warrant supplemental screening.

At this time, it is highly suggested that patient should initiate a dialogue with her physician, regarding the protocol to be followed after the diagnosis of dense breast. Each patient should be individually evaluated about her risk of breast cancer based on her genetics, family history and other risk factors.

One suggested approach based on a paper presented by Lee C. at Society of Breast Imaging/American College of Radiology Breast Imaging Symposium; April 26, 2015; Orlando, FL is to use tomosynthesis for all levels of risk, supplemental whole-breast ultrasonography for women with average risk, and supplemental magnetic resonance imaging for women with intermediate and high risk

For women who are at high risk and also have a contraindication to magnetic resonance imaging, whole breast ultrasonography or molecular breast imaging, if available, may be an appropriate alternative.

courtesy: https://www.moffitt.org/media/6369/125.pdf

The current options available in addition to screening mammography are Tomosynthesis or 3D mammography, Ultrasound, Magnetic Resonance Imaging (MRI), Molecular Breast Imaging (MBI) or Breast Specific Gamma Imaging (BSGI) and Contrast Enhanced Spectral Mammography (CESM)

Nancy M. Cappello, Ph.D. has founded Are You Dense, Inc., and Are You Dense Advocacy, Inc., to educate women and general public about the challenges women with dense breast face regarding the screening tools for detecting early breast cancer.

Classification of Breast Density: American College of  Radiology. 

click to enlarge

‘One size fits all’ breast imaging is a thing of past with new personalized breast exams by Automated Breast Ultrasound (ABUS).

Mammography misses 30% of breast cancers in dense breast which means that nearly 40% of women have the chance of missing breast cancer by simple screening mammography. Now it is possible to individualize breast imaging for each patient using multimodality approach.

Starting with personal and family history, followed by gold standard screening mammography with new technology of breast tomosynthesis, we can know the personal biology of the patient.

 Knowing that the woman has dense breast after the initial screening Automated Breast Ultrasound (ABUS) can be performed which increases the chances of cancer detections even after negative mammography.  

Using all this tool synergistically it is possible to increase the breast cancer detection rate by 55 percent over mammography alone.

More information about the ABUS by GE healthcare can be found here: https://obgynupdated.blogspot.com/2017/03/innovative-breast-ultrasound-system-for.html

More information about screening modalities other than mammography can be found here: https://obgynupdated.blogspot.com/2017/04/looking-beyond-screening-mammography-in.html

Know more about personalized breast cancer screening by watching this video.

Looking beyond screening mammography in the war against breast cancer.

Courtesy: MariaShriver.com 

Whenever we think of breast imaging, our first thought is mammography. The earliest record of mammography dates back to 1913 when German Surgeon Albert Salomon attempted to visualize cancer through radiogram but it was only in mid 60s that  mammography was introduced as a screening tool on mass scale for early diagnosis of breast cancer.

The technique has substantially evolved in last several decades, from direct-exposure films to digital. Digital mammography exposes the patient to much lower dose of radiation as compared to analog mammography and the images are clearer and can be viewed on computer.

New data analysis R. Edward Hendrick, Ph.D., shows nearly 275,000 breast cancer deaths have been averted since 1990, attributed to increased mammographic screening and improved therapies.

However, like other techniques, mammography is also not perfect and has its own limitations. 

According to ACS screening mammograms do not find about 1 in 5 breast cancers. Chances of missing the disease is higher if the patient have dense breast.

A recent study has shown that nearly 43% patients in USA have dense breast.

Many US states have laws requiring the mammography centers to inform patients about dense fibroglandular breast tissue and its impact on cancer diagnosis and detection rates.

courtesy of Hologic

Digital breast tomosynthesis (DBT) or 3D mammography is a new technique for mammography especially useful for screening women with dense breast. It includes multiple low-dose full-field projection images of the breast obtained from different angles that form an arc. The images are then used to reconstruct a 3D image of the breast, resulting in a clearer view without the distraction of overlapping tissue.

Currently there are four tomosynthesis systems on the market. Hologic’s Selenia Dimensions mammography, GE’s SenoClaire 3-D breast tomosynthesis, Siemens Mammomat Inspiration Prime with Tomosynthesis Option and Fujifilm Medical Systems U.S.A.

Another screening technique is whole breast ultrasound and breast magnetic resonance imaging (MRI).

Whole breast ultrasound is used along with screening mammography to pick up lesions that cannot be felt by hands and also not seen on mammography. It is done in the same sitting as screening mammogram. It is specifically useful for patients whose mammogram reported “Extremely dense breasts” (or density score of 4) or “Heterogeneously dense breasts” (or density score of 3).

It can be performed manually or by using Automated Breast Ultrasound System(ABUS).

GE Introduced a new version of its automated breast ultrasound system ‘the Invenia Automated Breast Ultrasound System(ABUS)’.

Breast MRI is another screening tool, it is not recommended for routine screening because it results in more false positives leading to anxiety and unnecessary breast biopsies.  It is recommended for screening women who are at high risk for breast cancer, usually due to a strong family history and/or a mutation in genes such as BRCA1 or BRCA2.

The American Cancer Society (ACS) recommends that all high-risk women with greater than 20% lifetime risk of breast cancer should have a breast MRI and a mammogram every year. For most women, these combined screenings should start at age 30 and continue as long as the woman is in good health.

Combined these three techniques are able to find another 20-40 percent more cancers than screening mammography alone.

Major American medical organizations with expertise in breast cancer care, including the American Congress of Obstetricians and Gynecologists (ACOG), American College of Radiology (ACR) and Society of Breast Imaging (SBI) continue to recommend that women start getting annual mammograms at age 40 and continue screening till women is in good health or life expectancy is less than 10 years.  

USPSTF advises to start screening at age 50 till 74 years with an interval of 2 years between screening.