Dense breasts and the risks of cancer


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Nancy Cappello’s mammogram results came back normal in 2003. So she was shocked when, just six weeks later, her doctor found a ridge under her right breast. She had advanced Stage 3 breast cancer that had spread to her lymph nodes, and her mammogram had missed it.

Cappello later found that she, along with 40 to 50 percent of American women older than 40, has “dense breasts.” That’s a classification that can increase the risk of breast cancer (as confirmed by a study published recently in the journal Radiology) and raise the chances that a mammogram won’t detect it. Dense breasts have more fibrous or glandular tissue and less fat than other breasts.

To help others and spread the word, Cappello launched a campaign that helped push a new law in Connecticut in 2009 requiring health-care providers to inform women if a mammogram reveals that their breasts are dense. About 35 states have passed similar laws, and about six more, plus the federal government, are considering similar legislation.

This is generally good news, but such laws also have the potential to cause confusion because many women and even many doctors are uncertain how to proceed with the information.

“I’m all for women having information, but there’s not evidence to support what to do,” says Karla Kerlikowske, a primary-care physician and a professor of medicine, epidemiology and biostatistics at the University of California at San Francisco.

Here’s what you need to know.

Extra cells, extra tissue
By itself, having dense breasts is just a moderate risk factor for breast cancer. While about half of women receiving mammograms have dense breasts, only about a quarter of that group has an increased risk of developing cancer that won’t be detected with a mammogram, Kerlikowske says.

Still, the risk is there.

The new Radiology study, for example, found that of about 108,000 women age 50 to 69 who had been screened for breast cancer between 2007 and 2015, those with dense breasts were 1.37 times as likely to have breast cancer as those with non-dense breasts.

Those with dense breasts were also nearly three times as likely as women with non-dense breasts to have an aggressive form of the cancer.

The study authors did note, however, that the absolute risk of these women getting breast cancer was still low: Just 5 of every 1,000 women with non-dense breasts got cancer, and 13 of every 1,000 women with dense breasts got cancer.

Dense breasts contain many more cells, connective tissue and collagen than less-dense, or fatty, breasts. More cells means more chances for one of them to become corrupted.

Dense breast tissue can also mask cancerous lesions on a mammogram, increasing the risk of a cancer going undetected. That extra tissue is the same shade of white as lesions or tumors on an X-ray, rendering mammography on dense breasts only 62 to 68 percent effective. That’s a big dip from the 85 percent effectiveness for women with fatty breasts.

One of the problems with the new laws, Kerlikowske says, is that they don’t tell you the extent of density — just that a woman has dense breasts. The degree of density matters. The more dense your breasts, the higher your risk.

“It’s like saying, ‘I’m notifying you that you’re tall,’ ” says Diana Buist, a senior scientific investigator with the Breast Cancer Surveillance Consortium and director of research and strategic partnerships at the Kaiser Permanente Washington Health Research Institute in Seattle.

It’s a characteristic of your physiology, she explains, but it’s unclear exactly how it might increase your chances of cancer and what you can do about that risk.

What you should do
Some states recommend that women with dense breasts pursue supplemental imaging, such as breast ultrasound or magnetic resonance imaging (MRI). But even then, Kerlikowske says, it’s not known whether supplemental imaging is effective at detecting cancers that aren’t identified on a mammogram.

Ultrasound and MRI can also be costly and time-consuming, Kerlikowske says.

The more imaging tests, the more chances of a false positive or finding a problem that isn’t clinically important. This could eventually subject a woman to invasive and unnecessary procedures such as a breast biopsy, not to mention anxiety and worry.

So what should you do if you have dense breasts?

First, don’t panic. Dense breasts alone aren’t enough to significantly increase your odds of developing cancer, Kerlikowske says. The most important thing is to ask whether your doctor can identify the degree of density, and then assess your overall breast cancer risk using online tools such as the Breast Cancer Surveillance Consortium Risk Calculator.

If you have dense breasts and other risk factors, such as a family history of breast cancer, pursuing supplemental imaging, such as ultrasound or MRI in addition to mammography, might be a good option.

“There’s no clear-cut strategy,” Buist says. “Be aware of your own risk, and understand where you stand on the spectrum.”