When JoAnn Pushkin was 45, she felt a lump in her right breast—which seemed odd since it had been only eight weeks since her annual exam. Mammographywhich she had been receiving conscientiously since she was 40 years old and which had led to a “normal” result.
Pushkin went to her doctor, who felt the lump and sent her for another mammogram and ultrasound. She was surprised when the technician casually told her, “You have dense breasts. This will be a very serious finding for us.”
And she was stunned when the lump she had felt – which was not visible on the mammogram – appeared as cancer on her ultrasound “clear as a bell.” This led to a double MastectomyChemotherapy, radiation, follow-up operations and the complication of chronic lymphedema.
But it also spurred Pushkin to action, joining a movement to push for a new federal regulation that would require mammography centers to inform patients about the density of their breasts.
This new rule, part of the US Food and Drug AdministrationThe updated mammography regulations came into force on Tuesday.
Pushkin had already requested notification from the FDA in 2010 after her treatments were completed and subsequently provided testimony as part of the proceedings.
She did this after learning that nearly half of all women over 40 have dense breasts, which carry an increased risk of breast cancer and also tend to spread the cancer to Mammographywhich makes detection difficult.
This also led her to co-found a non-profit educational institution, Information about dense breastsand to fight for the New York State Breast Density Information Act, which came into force in 2013 – one of Patchwork of state laws which require the disclosure of information about dense breasts, but not always about whether a patient has dense breasts. That’s just part of what makes the new rule important.
“At least there will be a uniform standard for all women in the United States that tells them whether their breasts are dense or non-dense,” says Dr. Wendie Berg, professor of radiology at the University of Pittsburgh School of Medicine and chief scientific adviser to Dense Breast Info.
But what does “dense breasts” really mean? And what should you do if you know you have them? Below you’ll find answers to all your questions about breast density and cancer prevention.
What does it mean to have dense breasts?
Breasts consist of fat and milk glands held together by connective tissue. The more glands and connective tissue a woman has than fat, the “denser” her breasts are.
Among women in their 40s, about 50% have some degree of dense breasts. This means that an astonishing half of all women are getting their first mammogram – which US Preventive Services Task Force For women who are recommended to have a mammogram at age 40 and then every two years, there is a risk that their breast cancer will go undetected during this mammogram.
Density is a spectrum, says Berg, and can change over time. In some breasts, density decreases after menopause.
And although doctors typically classify breasts into four categories — fatty (rare), diffuse (most common), heterogeneously dense and extremely dense — the new rule requires all mammography facilities to give their patients a standardized notification that says either “not dense” or “dense.”
But the specifics can be important, says Berg, because extremely dense breasts have at least four times the risk of breast cancer than fatty breasts, so it’s important to ask for clarification if you’re ever told you have dense breasts.
You have dense breasts, what now?
Although mammography has long been considered the gold standard for breast cancer detection, “I think it’s generally accepted that mammography is actually not a very good screening test for dense breast tissue,” says Berg. “This has been known for a long time.”
The reason for this is that dense tissue appears white on a mammogram, which also applies to cancer.
In fact, when breast tissue is extremely dense, “we miss at least half of all cancers in this type of tissue on mammography,” she says.
Fortunately, there are some alternatives: 3-D mammograms, so-called digital breast tomosynthesisand ultrasound, both of which can be somewhat more effective but also tend to produce false positives – as do mammograms, although these are less common the second and third time around, once a patient’s baseline condition is established.
And then there is MRI (magnetic resonance imaging), which is performed in conjunction with an intravenous dose of the contrast agent gadolinium. This is the most effective screening procedure for dense breasts – it is recommended by the American Cancer Society for women at increased risk of breast cancer. since 2007.
Not only are MRIs effective—the dark background makes most cancers “very easy to see,” Berg says—they are also widely available, making them a good choice “if you’re willing to have the contrast dye injected and if you don’t suffer from claustrophobia.”
And Berg also says, “If you know enough to ask about it,” as soon as you get your notice of dense breasts. “Every woman has to advocate for herself,” she stresses. “It’s very frustrating.”
The importance of breast self-awareness cannot be underestimated either, as 40% of diagnosed breast cancers are discovered by women who feel a lump, according to National Breast Cancer Foundation.
There is hope on the horizon: Contrast-enhanced mammographywhich uses existing equipment but combines it with the iodinated contrast agent used for CT scans.
“We get the same information as a regular mammogram, and we can also see the cancer cells much better because they … light up like a lightbulb on a black background,” says Berg, who has been involved in researching the technique for a decade, which is not yet approved by the FDA for screening purposes. “It looks very promising.”
Will my health insurance cover the costs of a breast ultrasound or MRI?
The Find it earlyset to be introduced in 2022, would ensure at the federal level that all health insurance plans cover screening and diagnostic mammograms, breast ultrasounds, and MRIs with no deductible or copayment. But until then, everything is a patchwork of rules and laws.
Currently there are 33 states plus DC who are required by law to expand breast cancer screening for women with dense breast tissue or other risk factors. However, laws vary – some only require that ultrasound scans be covered, for example.
Additionally, most insurance carriers are not subject to state law, which means that “even if there is a state law, your insurance may not cover the damage,” Berg says, noting that most will ultimately go along with it because it is more cost-effective.
“Earlier detection of cancer is better for the woman because the treatment is much less complex, but it is also better for the insurance company because it costs less. So from every point of view, it is an advantage to detect cancer early,” she says.
However, there will almost always be a co-payment or deductible, although this varies depending on the plan.
As an alternative for those who can afford it, Berg says some medical centers offer what is known as a shortened MRI, which is faster, is offered directly to patients (without a prescription), costs a fixed fee of about $250 to $600, and still has a higher cancer detection rate than mammograms.
And while the breast density reporting policy introduced this week was an important part of early detection, Pushkin says the hard-fought victory comes with a bittersweet aftertaste.
“When I heard the news, I sank heavily into my chair and thought, ‘God in heaven, this is finally over,'” she says. But then she thought of all the women whose cancer went undetected. “All of this happened on the backs of sick and dying patients,” she says.
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