From the Editor
Why is breast density a weighty matter?
What will you tell your patient who asks about the clinical significance of dense breasts detected on her mammogram? Here I offer my current...
These results suggest that there is a benefit to finding additional cancers with supplemental screening, though it is certainly possible that, as with mammography, some of the cancers found with supplemental screening are slow growing and may never have caused a woman harm even if left untreated.
Dense breasts: Medically sourced resources
Educational Web site
DenseBreast-info.org. This site is a collaborative, multidisciplinary educational resource. It features content for both patients and health care providers with separate data streams for each and includes:
a comprehensive list of FAQs; screening flow charts; a Patient Risk Checklist; an explanation of risks, risk assessment, and links to risk assessment tools; an illustrated round-up of technologies commonly used in screening; and state-by-state legislative analysis of density inform laws across the country.
State-specific Web sites
BreastDensity.info. This site was created by the California Breast Density Information Group (CBDIG), a working group of breast radiologists and breast cancer risk specialists. The content is primarily for health care providers and features screening scenarios as well as FAQs about breast density, breast cancer risk, and the breast density notification law in California.
MIdensebreasts.org. This is a Web-based education resource created for primary care providers by the University of Michigan Health System and the Michigan Department of Health and Human Services. It includes continuing medical education credit.
Medical society materials
American Cancer Society offers Breast Density and Your Mammogram Report for patients: http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-039989.pdf
American College of Obstetricians and Gynecologists’ 2015 Density Policy statement is available online: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Women-With-Dense-Breasts-Diagnosed-by-Mammography
American College of Radiology patient brochure details basic information about breast density and can be customized with your center’s information: http://www.acr.org/News-Publications/~/media/180321AF51AF4EA38FEC091461F5B695.pdf
What additional screening tests are available after a 2D mammogram for a woman with dense breasts?
Depending on the patient’s age, risk level, and breast density, additional screening tools—such as tomosynthesis (also known as 3D mammography), ultrasonography, or MRI—may be recommended in addition to mammography. Indeed, in some centers, tomosynthesis is performed alone and the radiologist also reviews computer-generated 2D mammograms.
The addition of another imaging tool after a mammogram will find more cancers than mammography alone (TABLE).14−17 Women at high risk for breast cancer, such as those with pathogenic BRCA mutations, and those who were treated with radiation therapy to their chest (typically for Hodgkin disease) before age 30 and at least 8 years earlier, should be referred for annual MRI in addition to mammography (see Screening Decision Support Tool FIGURE above). If tomosynthesis is performed, the added benefit of ultrasound will be lower; further study on the actual benefit of supplemental ultrasound screening after 3D mammography is needed.
Will insurance cover supplemental screening beyond mammography?
The answer depends on the type of screening, the patient’s insurance and risk factors, the state in which you practice, and whether or not a law is in effect requiring insurance coverage for additional screening. In Illinois, for example, a woman with dense breasts can receive a screening ultrasound without a copay or deductible if it is ordered by a physician. In Connecticut, an ultrasound copay for screening dense breasts cannot exceed $20. Generally, in other states, an ultrasound will be covered if ordered by a physician, but it is subject to the copay and deductible of an individual health plan. In New Jersey, insurance coverage is provided for additional testing if a woman has extremely dense breasts.
Regardless of state, an MRI generally will be covered by insurance (subject to copay and deductible) if the patient meets high-risk criteria. In Michigan, at least one insurance company will cover a screening MRI for normal-risk women with dense breasts at a cost that matches the copay and deductible of a screening mammogram. It is important for patients to check with their insurance carrier prior to having an MRI.
Should women with dense breasts still have mammography screening?
Yes. Mammography is the first step in screening for most women (except for those who are pregnant or breastfeeding, in which case ultrasound can be performed but is usually deferred until several months after the patient is no longer pregnant or breastfeeding). While additional screening may be recommended for women with dense breasts, and for women at high risk for developing breast cancer, there are still some cancers and precancerous changes that will show on a mammogram better than on ultrasound or MRI. Wherever possible, women with dense breasts should have digital mammography rather than film mammography, due to slightly improved cancer detection using digital mammography.18
Does tomosynthesis solve the problem of screening dense breasts?
