Why some doctors see a downside to informing women about dense breasts

Like many women, Shamma Mullen breathes a sigh of relief whenever she receives the good news of the results of her latest mammogram. But two years ago, Mullen's doctor sent her additional information that alarmed her.

She had thick breasts.

“I've never seen a letter like this before and I don't know what it means to have thick breasts,” said Mullen, 38, of Andover, Massachusetts. Mullen immediately went online to look for more information and called her doctor with questions about follow-up exams.

Women ages 40 and older in all states now receive notification of their breast density with their standard mammogram report because of new rules from the Food and Drug Administration. Massachusetts and 38 other states already have notification sent about breast density, which reflects the proportion of connective tissue in the mammary gland and adipose tissue. FDA requirements standardize these messages.

Dense tissue makes it difficult to find breast cancer on a mammogram; And that dense breast tissue Cancer risk factors.

You have thick breasts. and now

Mammography studies that show about half women over age 40 have denser breasts.

In the future, women with dense breasts will be encouraged to talk to their doctors and learn that “imaging tests other than mammography can help find cancer.”

Some health advocates argue that the notice oversimplifies a complex issue. They argue that without clear, evidence-based guidance, women can become scared, confused and frustrated.

Judith Garber, senior policy analyst at the Lone Institute, a nonpartisan health policy think tank, notes that there is no national standard for Chasing Thick Breasts Report

This means women will receive different advice depending on their doctor.

While some doctors will urge women to get additional screenings — such as an additional mammogram, ultrasound or MRI — others will advise women to simply continue to have regular mammograms, said Dr. Mark Perlman, professor emeritus at the University of Michigan School of Medicine, who attended the American College of Obstetricians and Gynecologists and wrote screening guidelines for the National Comprehensive Cancer Network.

“You can't counsel an entire population of women with dense breasts with a policy that works for everyone,” says Perlman.

Whether a woman can get additional images may depend on insurance, which doesn't always cover them, says Robert Smith, an epidemiologist and senior vice president of cancer screening at the American Cancer Society.

Smith said it's important for women to know if they have dense breast tissue.

Radiologist Organize the breast tissue Divided into four groups:

• Very dense
• Mostly dense
• Mostly fat
• Almost all fat.

Because breast cancer can hide behind dense tissue, “these cancers can grow larger and larger and more advanced until they finally appear in that dense corner and you see them,” Smith said. “When the disease is diagnosed, it is not early.”

“If the breast is completely dense, conventional techniques are simply not very accurate and additional imaging is needed,” adds Smith.

Hilary Marston, FDA chief medical officer, said notifications will empower women

“We really wanted to make sure women had the information they needed, in simple language, to make good decisions for their own health,” Marston said. “The most important thing is to make sure people have high-quality, clearly communicated information.”

Benefits and Risks of Additional Screening

Part of the confusion is that experts disagree about whether women with dense breasts need additional imaging tests.

Although the American College of Radiology and National Comprehensive Cancer Network recommend that women and their doctors consider supplemental screening, two other influential groups — the American College of Obstetricians and Gynecologists and the U.S. Preventative Services Task Force — say there is not enough evidence of benefits to recommend further testing.

And although additional testing may detect more cancers than just mammograms, there is no proof that additional testing saves lives, said Dr. Nancy Keating, professor of health policy at Harvard Medical School.

“We don't know the outcome. It's not going to be good at all,” adding more testing, Keating said. “We don’t know whether the benefits of additional imaging outweigh the harms.”

Additional imaging — such as ultrasound and MRI — supports risk, Garber said. Both tests “false alarms” may occur where benign tissue is identified as suspicious.

False alarms can lead to invasive biopsies that can be painful and cause bleeding, as well as pressure and unnecessary follow-up tests, some of which involve additional exposure to radiation or that color.

In some cases, excessive screening can lead to women being diagnosed and treated for cancers that never bothered them, problems known as overdiagnosis and overtreatment.

A study published in 2022 estimated that 15% of women aged 50 to 74 had breast cancer detected by mammography. was overdiagnosed. Ruth Etzioni, a biostatistician at the Fred Hutchinson Cancer Center and co-author of the study, points out that not all cancers are the same. Although some aggressive tumors grow quickly and require immediate treatment, others grow too slowly to harm women throughout their lives. Elderly women diagnosed with slow-growing breast tumors may die from other causes before the cancer develops.

Some research also Reliability is questionable System used to label breasts as dense or non-dense. A review article in the Annals of Internal Medicine found that 13% to 19% of women were reclassified to a different breast density category — from densest to densest or vice versa — at their next screening mammogram.

Chrissy Mattos said she had her first mammogram at age 40, but received her first breast lump warning this year at age 42. Matos, who lives in Stroudsburg, Pennsylvania, said she wondered why her breasts didn't appear dense on her first mammogram. Breasts tend to thicken in younger women.

Doctors recommend a second mammogram, this time using a new technology called digital breast tomosynthesis, often called 3-D mammography. An ultrasound showed that the suspicious area on her mammogram was not a cause for concern, Matos said.

The high cost of advanced imaging puts it out of reach for many patients. Women in rural areas or marginalized people often lack access to the latest technology.

Gerber, the Lone Institute analyst, said some of the FDA's language is confusing. While it is true that women have dense breasts 1.5 to 2 times more likely compared to other women to develop breast cancer, they are not likely to die from it.

The FDA's “reporting language encourages people to get more testing, when in reality testing is not really recommended” universally, Gerber said. “So the FDA is saying 'you have this breast density, you should be aware that you have an additional risk factor.' But then there's really nothing people should do about it. It’s a really scary place to be as a patient.”

The FDA's Marston said he hopes women and their doctors use the concentration warnings to have informed conversations. “We certainly don’t want to hide information from women,” Marston said.

Given the uncertainty about the benefits of additional screening, Perlman said the “safest and probably most accurate” way is to counsel women with dense breasts, adding, “We don’t know for sure what the best practice is at this point.”

Mullen said he was relieved when follow-up tests — which were covered by insurance — found nothing suspicious. But breast cancer “is always on my mind because of my family history,” Mullen said. Now that she knows her breasts are dense, “I think I would have been nervous if I hadn’t had the ultrasound.”