Clinical Review

Get smart about dense breasts

OBG Manag. 2015 October;27(10):18,20-23,26,27,45

References

Khong KA, Hargreaves J, Aminololama-Shakeri S, Lindfors KK. Impact of the California breast density law on primary care physicians. J Am Coll Radiol. 2015;12(3):256–260.
Sickles EA, D’Orsi CJ, Bassett LW, et al. ACR BI-RADS Mammography. In: ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2013.
Sprague BL, Gangnon RE, Burt V, et al. Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 2014;106(10).
American Cancer Society. Breast Cancer Facts & Figures 2013–2014. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042725.pdf. Published 2013. Accessed September 15, 2015.
Harvey JA, Bovbjerg VE. Quantitative assessment of mammographic breast density: relationship with breast cancer risk. Radiology. 2004;230(1):29–41.
Kerlikowske K, Cook AJ, Buist DS, et al. Breast cancer risk by breast density, menopause, and postmenopausal hormone therapy use. J Clin Oncol. 2010;28(24):3830–3837.
Arora N, King TA, Jacks LM, et al. Impact of breast density on the presenting features of malignancy. Ann Surg Oncol. 2010;17(suppl 3):211–218.
Smith RA, Duffy SW, Gabe R, Tabar L, Yen AM, Chen TH. The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am. 2004;42(5):793–806, v.
Warner E, Hill K, Causer P, et al. Prospective study of breast cancer incidence in women with a BRCA1 or BRCA2 mutation under surveillance with and without magnetic resonance imaging. J Clin Oncol. 2011;29(13):1664–1669.
Corsetti V, Houssami N, Ghirardi M, et al. Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow-up. Eur J Cancer. 2011;47(7):  1021–1026.
Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 2012;307(13):1394–1404.
Berg WA. Tailored supplemental screening for breast cancer: what now and what next? AJR Am J Roentgenol. 2009;192(2):390–399.
Brem RF, Lenihan MJ, Lieberman J, Torrente J. Screening breast ultrasound: past, present, and future. AJR Am J Roentgenol. 2015;204(2):234–240.
Hooley R. Tomosynthesis. In: Berg WA, Yang WT, eds. Diagnostic Imaging: Breast. 2nd ed. Salt Lake City, UT: Amirsys; 2014:2–19.
Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014;311(24):2499–2507.
Berg WA. Screening Ultrasound. In: Berg WA, Yang WT, eds. Diagnostic Imaging: Breast. 2nd ed. Salt Lake City, UT: Amirsys; 2014:9–43.
Berg WA. Screening MRI. In: Berg WA, Yang WT, eds. Diagnostic Imaging: Breast. 2nd ed. Salt Lake City, UT: Amirsys; 2014:9–49.
Hooley R. Tomosynthesis. In: Berg WA, Yang WT, eds.Berg WA. Screening Ultrasound. In: Berg WA, Yang WT, eds.Berg WA. Screening MRI. In: Berg WA, Yang WT, eds.Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353(17):1773–1783.

Tomosynthesis (3D mammography) slightly improves detection of cancers compared with standard digital mammography, but some cancers will remain hidden by overlapping dense tissue. We do not yet know the benefit of annual screening tomosynthesis. Without question, women at high risk for breast cancer still should have MRI if they are able to tolerate it, even if they have had tomosynthesis.

If a patient with dense breasts undergoes screening tomosynthesis, will she also need a screening ultrasound?

Preliminary studies not yet published suggest that, for women with dense breasts, ultrasound does find another 2 to 3 invasive cancers per 1,000 women screened that are not found on tomosynthesis, but further study of this issue is needed.

If recommended for additional screening with ultrasound or MRI, will a patient need that screening every year?

Usually, yes, though age and other medical conditions will change a patient’s personal risk and benefit considerations. Therefore, screening recommendations may change from one year to the next. With technology advancements and evolving guidelines, additional screening recommendations will change in the future.

Prepare yourself and your patients will benefit

The foundation of a successful screening program involves buy-in from both patient and clinician. Patients confused as to what their density notification means may have little understanding as to what next steps should be considered. To allay confusion, your patient will be best served by being provided understandable and actionable information. Advanced preparation for these conversations about the implications of dense tissue will make for more effective patient engagement.

Acknowledgment

Much of the material within this article has been sourced from the educational Web site DenseBreast-info.org. For comprehensive lists of both patient and health care provider  frequently asked questions, visit http://www.DenseBreast-info.org.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

References

Khong KA, Hargreaves J, Aminololama-Shakeri S, Lindfors KK. Impact of the California breast density law on primary care physicians. J Am Coll Radiol. 2015;12(3):256–260.
Sickles EA, D’Orsi CJ, Bassett LW, et al. ACR BI-RADS Mammography. In: ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2013.
Sprague BL, Gangnon RE, Burt V, et al. Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 2014;106(10).
American Cancer Society. Breast Cancer Facts & Figures 2013–2014. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-042725.pdf. Published 2013. Accessed September 15, 2015.
Harvey JA, Bovbjerg VE. Quantitative assessment of mammographic breast density: relationship with breast cancer risk. Radiology. 2004;230(1):29–41.
Kerlikowske K, Cook AJ, Buist DS, et al. Breast cancer risk by breast density, menopause, and postmenopausal hormone therapy use. J Clin Oncol. 2010;28(24):3830–3837.
Arora N, King TA, Jacks LM, et al. Impact of breast density on the presenting features of malignancy. Ann Surg Oncol. 2010;17(suppl 3):211–218.
Smith RA, Duffy SW, Gabe R, Tabar L, Yen AM, Chen TH. The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am. 2004;42(5):793–806, v.
Warner E, Hill K, Causer P, et al. Prospective study of breast cancer incidence in women with a BRCA1 or BRCA2 mutation under surveillance with and without magnetic resonance imaging. J Clin Oncol. 2011;29(13):1664–1669.
Corsetti V, Houssami N, Ghirardi M, et al. Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow-up. Eur J Cancer. 2011;47(7):  1021–1026.
Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 2012;307(13):1394–1404.
Berg WA. Tailored supplemental screening for breast cancer: what now and what next? AJR Am J Roentgenol. 2009;192(2):390–399.
Brem RF, Lenihan MJ, Lieberman J, Torrente J. Screening breast ultrasound: past, present, and future. AJR Am J Roentgenol. 2015;204(2):234–240.
Hooley R. Tomosynthesis. In: Berg WA, Yang WT, eds. Diagnostic Imaging: Breast. 2nd ed. Salt Lake City, UT: Amirsys; 2014:2–19.
Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014;311(24):2499–2507.
Berg WA. Screening Ultrasound. In: Berg WA, Yang WT, eds. Diagnostic Imaging: Breast. 2nd ed. Salt Lake City, UT: Amirsys; 2014:9–43.
Berg WA. Screening MRI. In: Berg WA, Yang WT, eds. Diagnostic Imaging: Breast. 2nd ed. Salt Lake City, UT: Amirsys; 2014:9–49.
Hooley R. Tomosynthesis. In: Berg WA, Yang WT, eds.Berg WA. Screening Ultrasound. In: Berg WA, Yang WT, eds.Berg WA. Screening MRI. In: Berg WA, Yang WT, eds.Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353(17):1773–1783.

Get smart about dense breasts

References

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From the Editor

Why is breast density a weighty matter?

Expert Commentary

Is supplemental ultrasonography a valuable addition to breast cancer screening for women with dense breasts?

Expert Commentary

Based on interval cancer rates, which women with dense breasts are most likely to benefit from supplemental imaging?