A Resident’s Primer on Breast Density
Are we communicating with our patients clearly about this controversial topic?
What Does Current Breast Density Legislation Entail?
In October 2009, Connecticut passed Public Act 09-41, requiring radiologists to communicate breast density information to patients undergoing mammography for both screening and diagnostic mammograms.
Since then, 23 other states have followed suit. The laws vary somewhat in the wording of the notices, but all seek to notify or to disclose breast density information to patients and to encourage further conversation with patients’ referring providers.
If the patient has either heterogeneous or extremely dense breast tissue as noted by the interpreting radiologist, a notice is provided to the patient that explains that her mammogram demonstrates that she has dense breast tissue, which could hide small abnormalities. Some state laws also include notice about supplementary screening tests depending on the patient’s individual risk factors. Lastly, patients are informed that a report has been given to their referring physician, who can address any questions or concerns.
What Are the Positives of This Legislation?
The legislation itself improves patient care by helping keep them informed of their breast composition and supplemental imaging modalities for further evaluation. Essentially, the power is given to the patient, which we can all agree is something we as physicians ultimately want for our patients. However, simultaneously, we want to provide the correct information so that patients can make the best informed medical decision.
What Are Some Potential Issues?
These potential issues are exactly what makes this a hot button topic. Although I agree that patients should be in control of their medical decisions, I also feel that we as physicians have an obligation to fully inform them of what breast density means and attempt to eradicate any misleading language in the letter that is sent to the patient.
In fact, this is what worries many breast radiologists in terms of breast density legislation: the language. Many primary care providers do not feel comfortable advising patients on screening related to dense breasts. Others do not possess the knowledge to adequately educate their patients on what having dense breasts means, let alone on what additional imaging a patient may need in their particular situation based on their personal profile.
Additionally, medical groups argue that the significance of tissue density is uncertain and that reporting it may needlessly panic women, leading to an avalanche of unnecessary screening examinations and biopsies, ultimately driving up the cost of health care.
An article was released last May in the Annals of Internal Medicine that stated that although increased breast density is a risk factor for developing breast cancer and makes cancer harder to detect because dense tissue can obscure masses, only about one half of women with dense tissue were at such a high risk that they needed additional tests. There is still much uncertainty in regard to how much weight should be placed on a patient’s breast density alone when ordering additional imaging and biopsies.
The bottom line is that instead of looking at breast density alone, patients and their doctors must consider other risk factors and tailor decision-making to each patient’s risk-factor profile.
How Could Breast Density Legislation Be Improved?
On the referring physician side, it is of the utmost importance that these clinicians receive better education about breast density, which will improve their ability to educate patients. Conversely, perhaps we as radiologists need to be at the forefront to educate these patients? Even adding that the patient may speak directly to the breast radiologist interpreting the mammogram, I think, could be another effective alternative. We need to support our patients in making sound decisions about their breast health.
By Amy K. Patel, MD (@amykpatel), chief resident at the University of Kansas–Wichita and former ACR RFS secretary