Breasts. Boobs. Titties. Ta-Tas. I can go on, but hopefully that gets any shyness out of the way.
Breasts are everywhere. They’re beautiful, practical and sometimes annoying and kind of silly, especially when jogging.
Breasts are also at risk for developing cancer. But, thankfully, we have modern medicine and tools to help catch breast cancer early and beat it.
When it comes to women with dense breasts, though, things get confusing. A debate is swirling if dense-breast care should routinely include an ultrasound screening along with a mammogram.
Why? Because dense breasts have more fibrous and glandular tissues than fatty tissue, which makes detecting cancer with a mammogram more difficult. Even with 3-D mammograms–the best type available–dense breast tissue can obscure cancer.
In fact, mammograms alone miss approximately one-third of breast cancer in women with dense breasts, according to The Brem Foundation, a non-profit organization dedicated to breast cancer education and early detection.
Trying to wade through the complex breast-density debate, is confusing for women. It has been for me. A good place to start is with these questions:
• What are dense breasts?
• How do you find out if you have dense breasts?
• How does breast density affects imaging?
Dense Breasts and Imaging
Ultrasounds are typically used as a secondary, follow-up step when something suspicious is seen on a mammogram. For women with dense breasts, there’s a push among health advocates for ultrasounds to be a first-step screening along with mammograms.
Cancer detection in dense breasts improves by over 55 % when screened with both mammography and ultrasound, according to Brem. And why is that?
Consider these facts about imagining and breasts gathered from Brem, Johns Hopkins Medicine and the Memorial Sloan Kettering Cancer Center:
Breasts consist of three types of tissue:
1. Glandular tissue (lobes and ducts used in milk production)
2. Fibrous tissue (also called connective or supportive tissue)
3. Fatty tissue. All non-fatty tissue is called fibroglandular tissue.
In a mammogram:
1. Fatty tissue appears clear.
2. Fibroglandular tissue and anything else present in a breast, such as calcifications and cancer, appear white.
3. In a fatty-tissue breast, a white spot of potential cancer is more noticeable.
4. In a dense breast, a white spot of cancer can blend in and be difficult to spot.
In an ultrasound:
1. Everything appears white except a potential spot of cancer.
2. Cancer stands out as black or dark gray and is easier to see.
With all these facts, someone might think an ultrasound alone is a good screening choice–
wrong. An ultrasound is NOT a substitute for a mammogram, but rather a supplemental tool.
Mammograms are the gold standard in detection and ultrasounds are not perfect. For example, ultrasounds, unlike mammograms, can miss tiny calcium deposits, which are an early sign of cancer. And, ultrasound results are less accurate on women with very large breasts.
How to Know if You Have Dense Breasts
Breast density can only be determined through a mammogram, not by touch and feel. The FDA updated it regulations in March 2023 to require mammography facilities to inform women of their breast density level. Some states already had similar regulations in place, but by Sept. 2024 all states must comply.
Results will include a woman’s Breast Imaging Reporting and Data System (BI-RADS) density classification (there is also a BI-RADS 0-6 numbering system that's used to describe findings on a mammogram). Developed by the American College of Radiology, the four BI-RADS density categories use letters and go from least to most dense as follows:
A – Almost all fatty tissue
B – Scattered areas of dense fibroglandular breast tissue
C – More areas of glandular and connective tissue (described as heterogeneously dense)
D – Extremely dense
The new mammogram reports are thoroughly explained on the American Cancer Society’s website. The reports will include:
1. A BI-RADS breast composition classification
2. Whether a woman’s breasts are either “dense” or “not dense.”
3. For those with breasts classified “dense,” the report will state:
“Dense tissue makes it harder to find breast cancer on a mammogram and also raises the risk of developing breast cancer. Your breast tissue is dense. In some people with dense tissue, other imaging tests in addition to a mammogram may help find cancers. Talk to your healthcare provider about breast density, risks for breast cancer, and your individual situation.”
What’s the Dense Breasts Debate All About?
There is consensus in the medical community, including the American Cancer Society, about the following:
• Dense breasts are common
• Women with dense breasts are at a higher risk of developing breast cancer
• Cancer is harder to spot in dense breast tissue
• Ultrasounds along with mammograms can catch cancer earlier
The debate centers on questions, such as cost effectiveness, cost versus survival benefit, and unnecessary subsequent testing. There is also a call for more research to assess these questions further.
On the American Cancer Society’s website, the organization acknowledges the benefits of extra imaging, such as ultrasounds and MRIs (magnetic resonance imaging), especially in high-risk cases.
Also, there's concern that for women with dense breasts and no signs and symptoms of cancer an ultrasound screening could “show findings that are not cancer” and “lead to more tests and unnecessary biopsies” that aren't covered by insurance.
The question of dense breasts and additional screening is currently under review by the U.S. Preventive Services Task Force (USPSTF), an independent group of health experts that make “evidence-based recommendations” about preventive services.
The USPSTF has the following included in a draft recommendation statement dated May 2023 on its website:
"Nearly half of all women have dense breasts, which increases their risk for breast cancer and means that mammograms do not work as well for them. Women are generally told by their clinician that they have dense breasts after they’ve had a mammogram. These women deserve to know whether and how additional screening might help them stay healthy. Unfortunately, there is not yet enough evidence for the Task Force to recommend for or against additional screening with breast ultrasound or MRI. We are urgently calling for more research on whether and how additional screening might help women with dense breasts find cancers earlier."
When I first read this statement, the words “not yet enough evidence” jumped out at me. What also jumped out, was the large “in progress” banner that stretched across a corner of the website page about the draft recommendation.
This topic isn’t new. For example, the first USPTF draft recommendation I found was dated 2016. And, the language was basically the same as the current statement.
So, there's still not enough evidence since 2016? The USPTF is just one group looking at the issue. What about all the other scientists, researchers and health professionals out there? When will the medical community reach a conclusion? And, meanwhile, how many women with dense breasts are missing the early-detection window?
Update! As of April 30, 2024, the USPTF published its "Final Recommendation Statement" on breast cancer screening (Note the sections in bold):
"Nearly half of all women have dense breasts, which increases their risk for breast cancer and means that mammograms may not work as well for them. Women are generally told that they have dense breasts after they’ve had a mammogram. These women deserve to know whether and how additional screening might help them stay healthy. Unfortunately, there is not yet enough evidence for the Task Force to recommend for or against additional screening with breast ultrasound or MRI. We are urgently calling for more research on whether and how additional screening might help women with dense breasts find cancers earlier.
It is important to note that all women, including those with dense breasts, should be screened starting at age 40. While we call for more research, these women should talk to their clinicians about their options for follow-up testing so that they can get the care that’s right for them."
I stand by my previous statements. How is there still not enough evidence?
Extra Imaging for Dense Breasts Can Hinge on Cost
A big factor in the dense-breasts care debate is the medical bill. Specifically, who pays it? Having a routine, preventative breast ultrasound is not covered by most insurance companies and it's an expensive out-of-pocket cost.
To combat this, U.S. Representatives Rosa DeLauro and Brain Fitzpatrick introduced the bi-partisan Find It Early Act in December 2022 and then again in May 2023.
The bill would require insurance plans to cover additional screening and diagnostic imaging, such as ultrasounds and MRIs, for women with dense breasts or at a greater risk for cancer.
High-profile journalist Katie Couric, who revealed she has dense breasts, is putting her star power behind the bill after her own breast cancer diagnosis.
“Breast cancer is treatable, and 99 % of women who are diagnosed early survive," said Couric when the bill was introduced. "That is why everyone needs to get screened. The Find It Early Act is a critical step toward improving access to these life-saving screenings."
Couric’s isn’t exaggerating. Of women diagnosed with early-stage cancer that has not spread beyond the breasts, 99 % survive it, according to data from the Office of Women's Health with the U.S. Department of Health and Human Services.
What Can Women with Dense Breasts Do Now?
Numerous organizations, including the National Cancer Institute and the American Cancer Society, squarely place only BI-RADS categories C and D in the dense breast column.
I pulled out my mammogram reports for the past several years and found it frustrating. I was classified with a BI-RAD C one time and then a B several subsequent times. Plus, one report included a long paragraph stating I "may" have dense breasts.
Huh?
My point is that it’s all a little mind numbing and confusing. There are so many studies and varying opinions. And, breast density can change with age and other factors. What are women with dense breasts or "may" have dense breasts supposed to do?
I’m not a medical professional, just a woman who wants to understand the best choices for my health. I’m learning just like everyone else.
Here's what I do know. We all have a unique combination of factors that go along with a BI-RADS classification, so what’s right for one of us may differ greatly from another. We have to advocate for ourselves, talk to our doctors and stay informed.
The breast density-care debate is certainly going to continue in the medical and political community. While they’re still debating, here’s some suggestions of what women with dense breasts can do in the meantime:
• Regularly have a mammogram without fail.
• Perform regular self-breast exams.
• Choose a 3-D mammogram, which is better for dense breasts since it provides a fuller picture of the entire breast than a traditional 2-D mammogram.
• Check with your insurance company about coverage since 3-D mammograms cost more and the difference may be out-of-pocket.
• Keep your annual mammogram reports with your breast density information.
• Know your family medical history and any potential risk factors for cancer.
• Talk to your doctor to assess your risk and if you should seek additional imaging.
• Check with your health insurance company to see if you have coverage for additional imaging based on your breast density.
• Check with an imaging facility and find out the costs of an ultrasound screening.
• Write your legislators in support of the Find It Early Act.
• Exercise, get enough sleep and eat a balanced diet.
• ALWAYS advocate for yourself!
For more information about dense breasts, women's health and breast cancer, including symptoms, visit these sites:
*Breast cancer ribbon image from Freepick.com
Thank you for this! As someone with dense breasts and early stage breast cancer I was shocked to find that my insurance wouldn’t cover ultrasound as preventative screening. I appreciate Katie Couric’s efforts to improve coverage for women in all states.