Women need to know more than just how dense their breast tissue is
June 9, 2015 12:00 AM
Wendie Berg, radiology professor at the University of Pittsburgh, is chief scientific adviser for a DenseBreast-info.org, a site developed as an educational tool for patients and health care professionals.
By Jill Daly / Pittsburgh Post-Gazette
It’s been more than a year since Pennsylvania required that all women receiving the results of their mammogram also be notified about the density of their breast tissue.
But how that density relates to their risk of breast cancer is still unclear — to both women and their doctors.
Breast density is described in a range of 1 to 4, with 1 being tissue that is mostly fat and 4 being tissue that is more fibrous and glandular than fat. Almost half of all women between 40 and 74 have dense breasts.
Dense tissue appears white on a normal mammogram, just as cancerous tissue does, and that makes it difficult for radiologists to detect cancer. Under the recent law — which also has been passed in 21 other states — patients must be told that although not abnormal, dense breasts “may be associated with an increased risk of cancer.”
However, which women with dense breasts are at risk for the most dangerous type of cancer is still not known. This is despite improved screening methods that can find cancer hidden in digital mammography, the predominant method now in use.
University of Pittsburgh radiologist Wendie Berg is professionally and personally invested in helping women understand breast imaging. She is chief scientific adviser for a new website DenseBreast-info.org, a site developed as an educational tool for patients and healthcare professionals.
The website provides women with a checklist to fill out and use when discussing their own breast cancer risk with a doctor. It also includes a flow chart for doctors to use, with screening recommendations tailored to a patient’s individual risk factors.
“I wanted to help other women get the information they need to advocate for themselves,” said Dr. Berg, who has dense breasts and has been treated for breast cancer herself.
Recent research published in the Annals of Internal Medicine confirmed that women with dense breasts are more likely to have cancer found as a lump within a year of a normal mammogram result — known as “interval cancer” and associated with aggressive tumors. The risk was highest in older women, and those with a family history of breast cancer.
The study concluded that other risk factors in addition to breast density, such as age and family history, should be considered when a doctor and patient are discussing additional screening.
“Unfortunately, a lot of doctors aren’t fully using current guidelines based on risk in their practice,” Dr. Berg said, in explaining that doctors are not taking the time to fully review their patients’ risk factors. Although they may ask about family history of cancer, she said “very few doctors are putting [their patients’ information] into the risk models.”
Mammograms are still valuable, she said. “Calcifications that go with cancer are easy to see in the mammogram. About half of cancers have calcification. We’re not going to give up on the mammogram.”
Right now, the U.S. Preventive Services Task Force guidelines recommend breast cancer screening every other year after age 50 for women without any symptoms.
William Poller, director of breast imaging for Allegheny Health Network, said the Annals study exposes weakness in the laws requiring women be told of their breast density and their additional risk of cancer.
“They were exactly correct, to say, ‘Whoa,’ ” Dr. Poller said. “They went overboard. Nobody knows for sure how many women with dense breasts are at high risk.” He pointed out if a woman and her doctor decide to go beyond a mammogram, the options for screening can be costly, subject women to unnecessary biopsies and are not always covered by insurance.
Tomosynthesis, or 3-D mammography, is considered more accurate, but uses more radiation and the additional cost may not be covered by insurance. Other supplemental screenings include ultrasound and magnetic resonance imaging (MRI), although they are associated with a greater number of false positive results.
“There is still a lack of information reaching patients to decide what type of additional screening is needed,” Dr. Berg said.
Mammograms will find about five cancers in 1,000 screenings. Another one or two will be found through tomosynthesis. Ultrasound finds about three more cancers.
“At UPMC our standard recommendation for extremely dense breasts is ultrasound,” Dr. Berg said. For others, tomosynthesis is recommended as a secondary screening.
Dr. Poller said Allegheny and UPMC have tomosynthesis technology. Although Medicare now reimburses the cost, insurers Highmark and UPMC Health Plan do not cover the screenings, so they are not being used regularly.
In its general policy guidelines, Highmark says, “There is limited scientific evidence supporting efficacy, therefore Digital Breast Tomosynthesis is considered experimental/investigational and non-covered.”
At UPMC Health Plan, Stephen Perkins, vice president of medical affairs, prepared a statement reinforcing the company’s commitment to effective screening and early detection of breast cancer, adding, “We are closely following the scientific literature, as it relates to the use of 3-D Mammography, or tomosynthesis, and are in discussions with our specialty physicians regarding if, and when, evidence for this methodology is strong enough to support reimbursement.”
Women who do fall into the high-risk category by way of strong family history, personal history or genetics should be screened every year with an MRI in addition to mammography, Dr. Berg said. It’s costly, but doesn’t use radiation.
“Right now we are not capturing most of the women who should be getting MRI,” Dr. Berg said. “About 6 percent should be.”
Dr. Poller heads a study, now recruiting and funded by GE Healthcare, to collect digital mammogram and tomosynthesis data as part of a larger future study.
“We want to see if tomosynthesis is really helping,” he said.
Finding smaller, invasive breast cancer is worthwhile, he said. “Right there you’re finding a cure. … We find it alarming insurance won’t pay.”
He said the insurance companies want studies that show improved outcomes in women’s health. “That’s very expensive and they take a long time, 10 to 15 years.”
“A definitive answer on which women, including those with dense breasts, are best served by which screenings will involve additional studies,” Dr. Berg said, “and that takes time.”
“All is not as simple as we would like it to be.”
Jill Daly: email@example.com or 412-263-1596.
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