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Published on June 18, 2018

Should you worry if you have dense breasts?Should you worry if you have dense breasts?

Massachusetts and more than 30 other states are now legally required to send mammogram patients notifications about the density of their breast tissue. But patients report the letters can be confusing – and unnerving.

Knowing why you are receiving the letter and what it means can help reduce anxiety surrounding these notifications.

“The first thing patients need to know is that dense breasts are common and normal,” said Cape Cod Healthcare radiologist Anne Morris, MD.

There are four categories of breast density, according to Dr. Morris including:

  • Fatty
  • Scattered
  • Heterogeneously dense
  • Extremely dense

“About 50 percent of women have heterogeneously dense or extremely dense breast tissue, which makes it more difficult to find breast cancer on a standard 2-D mammogram,” she said.

According to Dr. Morris, dense breast tissue and cancer both are white on a mammogram, so breast density notifications were intended by law to let patients know that radiologists may not be able to see cancer due to the density of their breast tissue.

“Women with dense breasts have a higher rate of breast cancer and should discuss their breast density status, its effect on their breast cancer risk, and the potential need for further screenings with their primary care physician,” she said.

Understand Why

Breast density reporting laws originated with Nancy Capello, Ph.D., whose advocacy resulted in Connecticut passing the first bill in 2009.

“My dense breast tissue remained hidden in my medical records for 11 years,” Capello said in an article on her web site, entitled Are You Dense? Exposing the best kept secret®.

When she was diagnosed with stage 3C breast cancer, Capello was finally told that her mammograms had revealed dense breasts that put her at higher risk for cancer and made cancer more difficult to detect.

The Massachusetts notification law went into effect in 2015.

Breast density notifications are meant to inform, not cause alarm. Because they were new, unexpected and can be difficult to read, some confusion arose.

A JAMA article, Content, Readability, and Understandability of Dense Breast Notifications by State, concluded that all breast density notifications they looked at were hard to understand. They recommended post-mammogram letters be written in a way that clearly and accurately inform women about their density status.

A recent Massachusetts-based study of primary care physicians at two undisclosed urban hospitals showed that 49 percent did not feel prepared to respond to patient questions about dense breasts. And 85 percent indicated interest in further education on how to manage patients with dense breast tissue.

Finally, a study of Massachusetts patients led by Boston University concluded that women they talked with were confused about breast density after reading their breast density notification letters.

Tomosynthesis Mammography

Dr. Morris expected to get questions from patients when notifications started being mailed several years ago, but that has not happened. The hospital’s approach to mammography may be the reason.

“We use the most advanced technology—tomosynthesis, or 3-D mammography—as the standard for screening mammograms,” she said. “At Cape Cod Healthcare, nearly everyone gets a 2-D mammography to compare against their prior mammogram and a 3-D mammography using tomosynthesis.

“With 3-D, we are already performing the test that is commonly recommended for women with dense breasts.”

Like conventional 2-D screening, 3-D mammography uses X-rays to produce images of breast tissue. However, unlike 2-D mammography, the 3-D machine moves around the breast, taking pictures at different angles in much the same way as a CT scan. The array of pictures creates a multi-layered, in-depth view. The extra dimension makes the tomosynthesis machine better at finding cancer in women with dense breasts, said Dr. Morris.

Only patients with tremors, those who have trouble holding their breath or who are unsteady on their feet are not good candidates for 3-D mammography.

Both 2-D and 3-D mammograms are available at Cuda Women’s Health Center in Hyannis and at Seifer Women’s Health and Imaging Center in Falmouth.

“I think it’s huge for patients that we’re able to find cancer early. We offer a better study using 2-D and 3-D mammography, which reduces unnecessary callbacks. A callback is when we need to call a patient to let them know they have had some abnormal finding. Most of the time it turns out to be nothing of concern, but callbacks increase anxiety,” said Dr. Morris.

State-of-the-art FAST MRI, an abbreviated and more cost-effective version of the standard MRI, as well as ultrasound, are both available at CCHC for patients who require further evaluation.

Beginning with each patient’s first mammogram, the hospital’s team of radiologists, breast surgeons, oncologists, technicians, nurses, receptionists and patient navigators go beyond the breast density notification to provide personalized care.

“If someone is called back because of a suspicious finding, we walk them through every step. We try to give patients a little extra something so they don’t feel alone,” said Dr. Morris.