Since Angelina Jolie shared her story with the world there has been much discussion about breast cancer and measures to prevent or early detect breast cancer. Sometimes it takes someone who is in the public eye to bring important medical issues to light. Although the Angelina story has proven to be very effective in making the public aware that surgery can reduce the risk of breast cancer in women who have inherited the breast cancer gene, in reality, only a small percent of women carry this mutation.
In April 2013 a new California law (SB-1358) went into effect that impacted risk assessment efforts in approximately half of all women receiving mammograms in Orange County. The new law requires that women who undergo screening mammograms which indicate dense breast tissue must be informed that such breast density is a risk factor for developing breast cancer, and that the density makes it more difficult to detect cancers on screening mammograms alone.
The hope is this law will allow women with dense breasts to be educated about their risk factors and the availability of alternative screening technologies that can sometimes detect cancers missed on mammography.
Breast Density as a Risk Factor
A recent study published in the Journal of the American Medical Association supports the need for this new law. The journal reported on a series of women with dense breasts who received a yearly screening ultra-sound in addition to their yearly screening mammogram. The study found that approximately one-third of the cancers detected on screening were seen only on the ultra-sound, one-third were seen only on the mammogram and slightly less than one third were seen on both studies. The study concluded that the addition of ultra-sound screening doubled the number of early breast cancers found in women with dense breasts.
About half of all women in Orange County receiving a yearly mammogram will be found to have dense breasts. Woman’s breasts are composed of a combination of fatty tissue and glandular/fibrous tissue. Fatty tissues produce a black background seen on a mammogram. Since most cancers show up as white spots, they are easily detected on mammograms in women with fatty breasts. Glandular tissue produces a white background. Some radiologists say detecting small cancers in a dense breast has been compared to looking for a snowman in a snowstorm.
Breast Ultrasound as an Additional Screening Option
For the 50 percent of women with fatty breasts the news is good. Mammograms are extremely effective in detecting small cancers in these women. However, and while ultimately beneficial, the new law also is likely to create anxiety and confusion for the other 50% of women who have dense breasts. The first challenge facing women with dense breast is likely to be financial. California law does not require insurance companies to pay for additional ultrasound screening studies, and the out-of-pocket costs are likely to range between $200 and $500.
Even if the cost issue can be surmounted, each woman must make a personal decision as to the relative benefit of subjecting herself to additional screening. This choice is made more difficult because of the ongoing debate on the value of mammography. Critics of screening point to the high rate of false-positive biopsies (biopsies on suspicious areas on the mammogram or ultra-sound that prove not to be cancer). Critics also note that despite three decades of mammography screening, the percentage of women diagnosed with advanced breast cancers has remained unchanged.
Yet proponents note that long-term studies of patients undergoing screening experience a greater than 30 percent reduction in breast cancer deaths. They also note that most women are willing to accept the anxiety associated with a negative biopsy in return for the potentially lifesaving benefits associated with early detection.
To me, the point that critics seem to be missing is that the addition of ultrasound to the screening process has the potential to reduce the number of advanced cancers by detecting those small but aggressive cancers that are missed on mammography.
In Orange County, where the rates for breast cancer remain higher than in other parts of the nation, Angelina’s story serves as a call to action for women with dense breast tissue. After all, having additional imaging is much less traumatic than having both breasts removed, but it can have the same lifesaving benefits.