Are You Dense?

This week, I attended a local oncology symposium reviewing the latest trends in oncology medicine. One of the speakers was Dr. Lawrence Mason, a radiologist specializing in women’s imaging. His talk specifically focused on what’s new in the world of imaging for breast cancer. Since October is breast cancer awareness month, I thought it was an appropriate time to ask, “Are you dense?”

Women with dense breast tissue are at a disadvantage for accurate and timely detection of breast cancer. Increased breast density has long been reported as a factor that decreases the sensitivity of mammography for the detection of early breast cancer changes. In fact, Dr. Mason noted that mammographic breast density is one of the strongest independent risk factors for breast cancer, possibly even stronger than age or family history in some cases.

He reviewed options available for these women, including:

• Digital mammography with density assessment
• Ultrasound
• MRI
• Digital Breast Tomosynthesis (DBT) -- nicknamed “Tomo”

He cited various studies showing the benefit of adding ultrasound or MRI following a mammogram revealing dense breast tissue. Benefits ranged anywhere from finding one additional incidence of cancer to 14 additional cases per 1,000 study patients. The downside with these more sensitive tests is they often lead to an increased number of false-positive readings and unnecessary biopsies.

DBT (Tomo) is 3D mammography, which takes a series of low-dose digital mammographic images acquired over roughly four seconds per image. The woman, unfortunately, has to have her breast compressed for up to 10 minutes (can we get a collective groan here?!).

Dr. Mason also shared something I found fascinating, though I’m not sure whether I’m saying that in a positive or negative light. Apparently, it has already been mandated in five states that women with dense breast tissue be informed, after their mammogram is read by a radiologist, that they 1) have dense breast tissue, and that 2) this makes it harder to evaluate results of the scan, and 3) places them at increased risk for cancer.

In Connecticut, this has led to further legislation requiring insurance companies to cover the cost of additional imaging in these cases, either ultrasound or MRI. You can read about this and see where your state falls at www.areyoudense.org.

The idea of “mandating” strikes me as odd, because in most states, the legislation has not led to the requirement of insurance companies to cover additional testing. It has simply mandated the transfer of knowledge to empower the patient to consider/question whether further imaging should be done. The underlying goal, I suppose, would be that mass breast cancer patients would begin demanding additional imaging, which would then lead to healthcare/insurance reform. But wouldn’t you think radiologists and oncologists are already telling women when they have dense breast tissue, without this mandate being necessary? If anything, creating legislation to require coverage from the insurance companies of additional testing seems like a better use of government energy/paperwork.

One other question I pondered was regarding women on the other end of the spectrum -- those with minimal breast tissue and imaging for this population. One could argue that perhaps women with very small breasts are more likely to feel a mass without mammography even being necessary. But I’ve seen a few patients where they lacked enough breast tissue for accurate mammogram (not enough tissue to squeeze, if you will), and this leads to ultrasound and/or MRI.

What has been your experience, if any, with this portion of the population? I wonder whether it is harder for these women to get insurance coverage for a more expensive scan up front, or whether it’s just a matter of coding it correctly?

In the end, big or small, embrace them all... and educate yourself on what imaging you should be receiving, and what you should be recommending to your patients!