New law aims to make breast cancer testing more effective

By Robin Erb, Detroit Free Press

Updated 8h ago

Women with dense breast tissue — the sort that can hide potentially deadly tumors from routine mammograms — must be notified in writing and encouraged to consider additional tests under a new state law that is effective Monday.

Dr. Renee Wayne Pinsky, who specializes in breast imaging, takes a break from examining scans at the more

While mammograms remain the gold standard for detecting breast tumors, they're less reliable in almost half of women with dense breast tissue. Dense or fibrous tissue shows up as splotches of white on a mammogram — so do tumors.

That will likely surprise many of the millions of women who rely on mammography for catching the earliest signs of cancer, said Nancy Cappello. The Connecticut woman was shocked in 2004, when her gynecologist found a lump — advanced cancer that had already spread to her lymph nodes — just months after a mammogram deemed her cancer-free.

"I'm thinking, 'Why do you think I'm getting my breasts squeezed every year and getting radiation (from mammograms) every year? It's supposed to find my cancer," she said.

Cappello has been fighting for years for mandatory notification laws across the U.S. and established the www.AreYouDense.comweb site to raise awareness about the limits of mammography in dense breast tissue. Inspired by Cappello's efforts, Grand Rapids attorney Teresa Hendricks-Pitsch, pushed for the new Michigan law. She even wrote out arguments for the law in 2011 while hooked up to a chemotherapy drip to fight cancer that had spread to her lymph nodes.

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“We’re not going to diagnose all cancers on mammography,” says Dr. Renee Wayne Pinsky, a radiologist who says more

Hendricks said a surgeon who excised her tumor told her it most likely had been growing for years. Hendricks-Pitsch's annual mammograms also missed the cancer.

If women know about the limitations of mammograms in dense breast tissue, they can opt for follow-up screenings — ultrasounds or an MRI, for example, the women said.

Both said their health care providers knew about the presence of dense breast tissue, but no one told them or suggested additional testing or follow-up exams.

"My radiologists knew about it. My doctor knew about it," said Cappello. "Everybody seemed to know about it but me."

In Michigan, Hendricks-Pitsch said some have suggested she file a lawsuit. A change in law makes more sense, she said: "I want other women to have the information I didn't."

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A woman gets a mammogram at the U-M center on Friday.

 (Photo: Kimberly P. Mitchell/Detroit Free Press)

Exams aren't perfect

Perhaps the first step in understanding is knowing this: Finding cancer in a mammogram is a matter of interpretation — the ability to discern an abnormality from a canvass of threads and splotches and spots in black and white and shades in between.

Dr. Renee Wayne Pinsky, a radiologist at the University of Michigan Comprehensive Cancer Center, likens it to searching for a cotton ball in a snowstorm.

In a breast with fatty, less-dense tissue, the whiteness is more scattered against a gray and black landscape. An anomaly — such as a cotton ball — is easier to spot, said Pinsky.

But trying to read a scan of a dense breast tissue is more like peering through a fierce blizzard, trying to glean from a mostly white background a malignant whiteness.

"We're not going to diagnose all cancers on mammography," said Pinsky, who helped fine-tune some of the language in the law, which was introduced by Sen. Dave Hildenbrand, R-Lowell, who represents Hendricks-Pitsch's district.

Though some lawmakers and health providers raised concerns about the extra time demands on doctors, about insurance coverage and about causing unnecessary worry among patients, Michigan approved the bill in December. Gov. Rick Snyder signed it Jan. 10.

Michigan is among 22 states now with some law addressing raising awareness among women about the limits of mammograms in dense breast tissue.

The Medio-lateral Oblique scan on the left shows a fatty breast compared to the breast on the right, which more

Mammogram reports sent to doctors routinely contain information about breast density, but — without a law — its importance in screening is not always passed along to patients or discussed in a way that it's easily understood, said U-M's Pinsky.

And women with extremely dense breasts may face a twofold increased risk of breast cancer than they would if they had less-dense breasts. But Pinsky and other experts also say dense breast tissue doesn't necessarily justify more testing. On its own, dense tissue is not a cause for alarm.

"If you get the letter, the first thing I would tell you is not to worry (about dense breast tissue). It's a common factor," said Dr. Murray Rebner, chief of breast imaging at Beaumont Hospital in Royal Oak and a past president of the national Society of Breast Imaging.

Rather, it's one of many variables that are sifted into a woman's breast cancer risk calculus, he said. Others include family history, age, the age when a woman began menstruating, and the age when she first gave birth.

If a patient's level of risk warrants more testing, there are several options, including ultrasounds, that use sound waves to peer inside the breast, magnetic resonance imaging (MRI), which uses magnetic fields, or molecular breast imaging, which uses a higher dose of radiation than mammograms but has a high rate of cancer detection.

However, unlike routine mammograms, which are free under federal health reform because they're considered a preventive service, insurers differ on how they cover those tests. Blue Cross Blue Shield of Michigan and Health Alliance Plan, two of metro Detroit's largest insurers, say they cover such tests on a case-by-case basis, for example.

Cappello said the cost shouldn't discourage women from talking to their doctor. It is the doctor, she said, who can help them better understand the risk, sort through pros and cons of follow-up exams and help them work with insurers.

Contact Robin Erb : 313-222-2708, rerb@freepress.com or on Twitter @Freephealth

Dense Breasts May Obscure Mammogram Results

By RONI CARYN RABIN

 JUNE 16, 2014 4:54 PM

Damian Dovarganes/Associated PressDense tissue can make a mammogram seem like “looking through a window with snow on it.”

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The doctors were pleased to inform me, the letter said, that the results of the mammogram were normal. Early detection of cancer is important, a report was sent to my referring physician, I should report any lumps, see my health provider, have a physical.

A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”

In journalism, we call this “burying the lead” — tucking the really significant information far down in the story. I knew that having dense breast tissue makes it hard to read mammograms and may increase the risk of breast cancer. I just never knew I had dense breasts.

I’ve had at least half a dozen mammograms, and each one has come back normal. Now I discover these images have been obscured. Dense tissue shows up white on the scans. So do tumors.

“It’s like looking through a window with snow on it, searching for a drop of milk,” said Dr. Carolyn D. Runowicz, a professor of obstetrics and gynecology at the Herbert Wertheim College of Medicine at Florida International University in Miami.

No wonder mammograms miss half of all breast cancers in women with dense tissue.

About 40 percent of women who have mammograms have dense breast tissue, which means they have more connective and fibrous tissue than usual. Until recently, that information was rarely relayed to women, though it was routinely noted in the radiologist’s medical report to the doctor (as “dense parenchyma” that “lowers the sensitivity of mammography”).

Now women from Hawaii to California, New Jersey to New York, are receiving letters about their breast density because of state legislation championed by Nancy Cappello, a 61-year-old Connecticut woman. Her breast cancer had spread to her lymph nodes by the time it was diagnosed 10 years ago, even though she had had normal mammograms every year.

Her tumor was an inch in size when it finally became palpable, Ms. Cappello said in an interview. Her doctor estimated it had been growing for four or five years, even as Ms. Cappello went faithfully for mammograms and received assurances that she was cancer-free. No one warned her that dense breast tissue could obscure the radiologist’s view.

Unfortunately, there’s still no clear medical guidance on how women should proceed once they’ve been told they have dense breasts. Some experts even question whether having dense breasts significantly increases breast cancer risk.

The letters mandated by New York law suggest women “use this information to talk to your doctor about your own risks for breast cancer” and ask their doctor “if more screening tests might be useful.” The Connecticut law goes further; women with dense breasts are told to consider an ultrasound or magnetic resonance imaging test.

But the American Congress of Obstetricians and Gynecologists doesn’t recommend using additional screening tests just because a woman has dense breasts. The American College of Radiology acknowledges that other types of scans may detect tumors missed on mammograms, but notes that there are no good data showing that women who add an ultrasound or an M.R.I. to mammography live longer.

I did what the New York letter suggested: I called my doctor. He emailed back right away, saying he was not concerned. The density of my breasts was not news to him.

I called my health plan to see if it would cover an ultrasound. I was pleasantly surprised: It would, though not at the same rate as a mammogram, which is considered preventive care that most health plans must cover in full.

Then I called the radiology center to make an appointment, and learned I could drive over and pick up a CD with my mammography images on it at no charge.

I picked up the disc and popped it in my computer. As soon as the images appeared on screen, I could see what the doctors were talking about: Big white clouds were floating in the middle of each dark half-moon image.

“One thing women shouldn’t do is start to worry that there is something wrong” if she has dense breast tissue, said Dr. Carol Lee, a diagnostic radiologist at Memorial Sloan Kettering.

Although the benefits of routine mammography have been debated for years, many women continue to choose it, and experts say they need not stop just because they have dense breasts.

“Mammograms pick up cancers in women with dense breasts every day,” Dr. Lee said.

For dense breasts, however, a digital mammogram is preferable to film, and a three-dimensional mammogram is even better, Dr. Runowicz said.

But there’s a definite downside, other experts note: Additional scans will pick up other suspicious spots that may require intervention, such as biopsy to rule out cancer, even though most of them will turn out to be harmless. Learn about your risk factors for breast cancer at cancer.gov (breast density is not listed here), and use the online calculator to gauge your risk. A woman’s risk increases with age.

Talk to a trusted physician and consider adding an ultrasound or an M.R.I. scan to your screening if you have dense breasts. An ultrasound is cheaper and less invasive, said Dr. Regina Hooley, an assistant professor of diagnostic radiology at Yale.

Mammograms pick up two to seven cancers per 1,000 women screened, and subsequent ultrasounds pick up another three to four small invasive cancers, Dr. Hooley said. Even though there may not be scientific evidence proving a survival benefit from the additional scans, she said, “these are exactly the cancers we want screening to detect.”

A version of this article appears in print on 06/17/2014, on page D6 of the NewYork edition with the headline: Obscuring Mammogram Results.

http://well.blogs.nytimes.com/2014/06/16/dense-breasts-may-obscure-mammogram-results/?_php=true&_type=blogs&partner=rss&emc=rss&_r=0

What Women Should Know about Breast Density

Diagnostic Radiologist Carol Lee Discusses What Women Should Know about Breast Density

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By Media Staff  |  Wednesday, January 30, 2013

A new law requires radiologists to inform women if dense breast tissue is found on a mammogram.

To help improve breast cancer detection and prevention, New York Governor Andrew Cuomo recently signed legislation that requires radiologists to inform women if dense breast tissue is found on a mammogram. The law, which went into effect this month, is raising awareness among women about this topic.

In an interview, we discussed the concept of breast density with diagnostic radiologist Carol H. Lee. Dr. Lee suggests that if you find out you have dense breasts, you should discuss potential next steps with your doctor. Each individual woman’s risk for breast cancer is different, and many factors – such as family history and lifestyle – must be taken into account when determining whether additional forms of breast cancer screening are necessary.

What are dense breasts?

Breasts are made up of different types of tissue: fatty, fibrous, and glandular. Fibrous and glandular tissues appear as white on a mammogram and fatty tissue shows up as dark. If most of the tissue on a mammogram is fibrous and/or glandular, the breasts are considered to be dense.

Because cancer cells also appear as white on a mammogram, it may be harder to identify the disease on a mammogram in women with dense breasts.

How common are dense breasts?

Breast density is classified into one of four categories, ranging from almost entirely fatty (level 1) to extremely dense (level 4). Dense breasts are completely normal. About half of all women have breasts that fall into the dense category (levels 3 and 4). Dense breasts tend to be more common in younger women and in women with smaller breasts, but anyone – regardless of age or breast size – can have dense breasts.

How does a woman know she has dense breasts?

The only way to determine whether a woman has dense breasts is with a mammogram. A breast exam cannot reliably tell whether a breast is dense.

What does having dense breasts do to a woman’s risk for breast cancer?

If you compare the 10 percent of women who have extremely dense breasts with the 10 percent of women who have very little breast density, the risk for breast cancer is higher in those with very dense breasts.

However, most women fall somewhere in between in terms of breast density, so it’s nearly impossible to determine whether a particular woman’s breast density is a risk factor for the disease.

What should women who are told they have dense breasts do?

Women found to have dense breasts should talk to their doctors about their individual risk for breast cancer and together decide whether additional screening makes sense.

Tests such as ultrasound or MRI can pick up some cancers that may be missed on a mammogram, but these methods also have disadvantages. Because they are highly sensitive, they may give a false-positive reading, resulting in the need for additional testing or biopsy that turns out to be unnecessary. There is also no evidence to show that using screening tests other than mammography in women with dense breasts decreases the risk of death from breast cancer.

Ultimately, women who have dense breasts should weigh the pros and cons of additional screening with their doctor.

Should women who do not have dense breasts make any changes to their regular screenings?

Women who do not have dense breasts may still develop breast cancer, and should continue to receive regular mammograms. Regular mammography is the only screening method that has been shown to decrease deaths from breast cancer, and all women of appropriate age should have mammograms, regardless of their breast density.

http://www.mskcc.org/blog/diagnostic-radiologist-carol-lee-discusses-what-women-should-know-about-breast-density