It is October, and we know October brings with it not only brightly colored leaves as fall sets in, but the bright color of PINK – everywhere! Most of us know October is Breast Cancer Awareness Month. The pink ribbons and pink products remind us of the importance of breast screening and encourage us to donate to organizations that support breast cancer screening and prevention.
What we don’t see, however, in October or any other month, is enough information being shared with women about the true nature of mammography screening, the accuracy related to the density of a woman’s breast tissue or the need to ask questions of your physician regarding our own personal risk related to breast tissue density.
It can be confusing to understand the different types of mammography available. As a standard, there are two main types of mammography most often used for breast imaging. Those types of imaging are often referred to as “2-D and 3-D mammography,” or digital tomosynthesis. The difference is exactly the way it sounds – the 2-D image shows a 2-dimensional image of the breasts, and the 3-D image shows a 3-dimensional image of the breasts. The procedure is the same for both. In 2011, 3-D imaging became the “standard” for breast imaging, although some healthcare providers still do not have 3-D imaging equipment. Three-dimensional images have been found to be more accurate in finding lesions than two-dimensional imaging. 1
That said, the important factor that many are unaware of is the density of a woman’s breast. Depending on the density of the breast, which reflects the amount of fibrous and glandular tissue in the breast, both two-dimensional and three-dimensional imaging may be less effective in detecting breast cancer. There are four levels of density when evaluating breast tissue, with level 4 density representing “extremely dense” breast tissue. What does that mean? Well, in short, it means that the tissue is so dense that it can easily hide breast cancer, because the denseness of the tissue appears very white on imaging, and cancer can be obscured from view. 2
The most important thing you can do is – ask your radiologist or the primary care physician what your radiology report says about the denseness of your breast tissue. In 2017, Governor Bevin passed law HB 78, which requires mammography providers to report findings of dense breast tissue to patients.3
The law does not require providers, however, to discuss the different types of dense breast tissue, or recommend additional imaging. Unless you request a copy of the actual radiologist’s reading to discuss with your referring physician, you may not receive enough information to help guide future decisions around breast imaging.
I lost my mom to breast cancer in 2013. After being diagnosed with DCIS, Stage 0 (now considered precancerous/unlikely to metastasize or spread to other areas of the body) when she was 50 years old, she underwent the recommended lumpectomy, received radiation treatment and took hormone-blocking medication for five years as advised. She continued to have standard follow-up mammograms for the next 10 years as advised. In September of 2011, she had a routine mammogram that was read as “negative for indications of cancer.”
In July of 2012, she was diagnosed with stage 4, terminal breast cancer, and it had spread to her bones, liver, lungs and abdomen. Why didn’t her mammogram in September show any signs of cancer? Why did the follow-up PET scan clearly show cancer in the same breast as the previous cancer appeared? You guessed it – dense breast tissue. Basically, the mammograms she had been having for 10 years were very unreliable. She had extremely dense breast tissue, in addition to scarring from her lumpectomy and changes in tissue due to radiation. At that time, even after having had cancer, no one ever recommended a more accurate form of breast imaging. Since I lost my mom in May of 2013, I have had three close co-workers develop breast cancer. I have had two team members whose close family members have developed breast cancer. And my 45-year-old, vibrant, wonderful best friend was diagnosed with breast cancer in 2019, only to have it recur in 2021 as terminal cancer. In almost all these cases, the women had dense breast tissue, and no one had discussed with them alternatives to routine mammography.
So, my advice for all women is to ask your physician for more detailed information about your breast density. Educate yourself regarding the various options that exist for more detailed breast imaging if you have any level of dense breast tissue and/or a family or personal history of breast cancer. If you are a breast cancer survivor who is still undergoing standard mammography, absolutely advocate for additional screening. Ultrasounds, Tomosynthesis with contrast or MRI imaging might be a choice for you. And, if your insurance denies any one of those imaging modalities, appeal or think about planning ahead using a healthcare savings account to pay the difference. Your life may just depend on it.
Above all – advocate for yourself. I recently had an MRI that showed an abnormal finding. As a woman with 37% higher likelihood of developing breast cancer and having extremely dense tissue (the worst kind), I advocated for a biopsy even when a follow-up ultrasound showed “likely benign” findings. Even though it was hard, I pushed back on the radiologist, explained my family history in more detail, and he agreed. I had a biopsy that showed it was, indeed, negative, and I didn’t have to worry about the “what-ifs” every day.
For more information on breast density, go to https://densebreast-info.org/. It is a comprehensive resource for learning about dense breast tissue, what it means and steps you can take to find out the degree of density of your breast tissue, as well as alternatives to standard mammography.