Breast density, and how it affects the detection and treatment of breast cancer, is increasingly becoming a topic of discussion amongst patients, doctors and even politicians. Recent legislation passed in many states, including California, now require mammography centers to inform patients if they have dense breast tissue.
Dense breast tissue is made-up of more connective tissue than less dense, or fatty, breast tissue. As a result, dense breast tissue appears more white on a mammogram, making it harder to identify some cancers. Equally important is the four-fold increased rate of breast cancer associated with increased breast density. That is to say that not only is it harder to detect breast cancer with a mammogram in patients with dense breasts, it is also more likely for patients with dense breasts to develop breast cancer.
Radiologists classify breast density into one of four types using the Breast Imaging-Reporting and Data System (BI-RADS) classification.
“Should Breast Density Influence Patient Selection for Breast-Conserving Surgery?”
During part of my training at Memorial Sloan Kettering Cancer Center in New York, I, along with several collaborators, decided to investigate breast density and it’s correlation with cancer development and treatment. In an earlier study, we found that patients with dense breasts were developing similar types of cancers as patients with fatty breasts, but they were more likely to undergo mastectomy. In my more recently published study, “Should Breast Density Influence Patient Selection for Breast-Conserving Surgery?”, we explored why this was happening.
We were interested in finding out why breast cancer patients with dense breasts were more likely to have mastectomies instead of breast-sparing surgery (lumpectomy) compared to cancer patients with less dense breasts. I was the first-author on this study involving 1,056 patients treated for breast cancer, and it was recently published in the February 2013 issue of the Annals of Surgical Oncology. I encourage you to view the full article.
One possible hypothesis was that patients with dense breasts were developing multiple areas of cancer in the breast (multifocal or multicentric breast cancer) that would prevent them from safely undergoing lumpectomy to remove all the cancer. Another possibility was that they were developing larger cancers or cancers with other characteristics such as extenstive intraductal component (EIC) that are known to lead to more margin positivity (cancer seen at the margin, or edge, of the lumpectomy) leading to further excisions and ultimately mastectomy in order to remove all the cancer in the breast.
We were surprised to find that none of these hypotheses were correct; instead, patients with dense breasts were frequently undergoing mastectomy without even attempting lumpectomy. They were not more likely to have cancer at the margins if they did have a lumpectomy compared to their less dense counterparts. Instead, more likely, these cancer patients with dense breasts were having mastectomies for other, more subjective reasons that could not be found in pathology reports or from their clinical histories.
Since we could not identify a clinical or pathologic factor associated with mastectomy selection in dense-breasted patients, I suspect there may have been a more hidden, emotional component involved in the decision for mastectomy. I wonder if many of these patients, and likely their treating physicians as well, may have chosen mastectomy instead of lumpectomy based on their breast density alone. Knowing the higher risk of cancer development in dense breasts and knowing the difficulty of detecting breast cancer in dense breasts, the fear of future breast cancers could have been enough to choose mastectomy over lumpectomy.
This study highlights the importance of not only knowing the biology of breast cancer and breast density, but the real, daily significance of understanding patient fear and their emotional vulnerability while making surgical treatment decisions. I do not believe that patients with dense breasts should all undergo mastectomy. I do believe, however, that educating patients about breast density is critical and that as clinicians we must help our patients make informed treatment decisions.
I am almost 6 years out now and wonder what is the best screening for those of us with dense breasts and a history of breast cancer. I had an axilla presentation in the nodes only and did not require any breast surgery, just axilliary node desection, chemo and radiation. Thank you Sandi
Hi Sandi, thanks for your question. I believe in individualizing every patient’s follow-up plan so it is not so simple to generalize. You, especially, seem to have a less common form of cancer presentation and would benefit from a more thorough discussion with your physician about best follow-up.
Most women over the age of 40 with dense breasts need a mammogram and ideally additional screening with either screening ultrasound and/or MRI. 3D digital mammography can be very helpful compared to older forms of mammography. If you would like to set up an appointment with us to discuss your individual case please feel free to contact our office at 714.541.0101.
King regards,
NSK
I am 42 and went for a mammogram 6 months ago and they said I needed an ultrasound also because of dense breast tissue. I saw a surgeon and she said I should have a needle biopsy. I went for the biopsy and she consulted with the radiologist in the hospital and both agreed I didnt need it. What they wanted to biopsy was no longer there. (to my knowledge, dense tissue). She never said anything about a lump or anything suspicious. She said 6 months for another mammo and ultrasound. So I just went last week, the surgeon felt it was different and worse than before. She had me go for a 3D mammogram and she now said I need to have surgery to take out the dense breast tissue. Im not sure I asked the right questions and feel maybe I should have asked more. I just felt if she saw something that needed to come out then I should go ahead with the surgery. I go in 3 weeks and am very concerned. She didnt explain enough why she was doing surgery.
Hi Krista, I believe it is very important for patient’s to be empowered to ask questions of their medical team when facing the potential of a significant medical treatment. I recommend asking enough questions until you feel comfortable and to follow-up with phone calls if needed. You can always seek a second opinion. I always prefer to only provide medical advice on a patient’s specific case in a private, secure setting. However, I believe Komen has provided a number of relevant questions to consider asking your medical team when you see them next —>
komen.org/BreastCancer/QuestionstoAsktheDoctorPDFDownloads.html
Please feel free to contact my office at (714) 541-0101 if you would like to set-up an appointment with myself or one of my colleagues.
Best, – Dr. Kapoor
I have dense brest tissue and I have had a lump that one year ago the radiologist said was a fat filled cyst but one year later its still there do you think i should have had a byopsy? i feel my nipple on looks sinkin a bit on side i have the lump
Most breast lumps are not breast cancer. Having dense breasts with new lumps can be challenging to diagnose. Fortunately, with 3D mammogram, ultrasound, and MRI, these diagnostic challenges are easier to tackle.
Nipple changes can sometimes be a sign of an underlying breast cancer. Lobular breast cancers, for example, can cause some changes in the breast and nipple, but the cancer itself may be hard to detect on imaging, especially in dense breasts. The decision to do a biopsy should be discussed with a dedicated breast surgeon if possible.
Ultimately you have to be your own advocate. If you are not satisfied with answers you get from one practitioner, continue to seek additional opinions.
I have a question . I had a mammogram 2 weeks ago. It was clear however they did tell me my breast tissue is very dense. As I have researched “dense breast tissue”, I have learned I am at greater rate for breast cancer. I am 54 and have a DD since age 16. I have wanted a breAst reduction. Now I just want a profolatic masectomy! I am seeing way too many women with breast cancer!!!. Would insurance pay for these procedure?
Hi Sherri,
Many women have faced anxiety and confusion after receiving a letter that they have dense breast tissue after a mammogram. Having dense breasts is one of many risk factors for future breast cancer, whereas having large breasts is not necessarily a risk factor. I urge you to speak to your doctor for a better understanding of your unique risk factors.
Breast reduction and prophylactic (preventive) mastectomy can be covered by insurance if considered medically appropriate depending on individual risk. Speaking with both a board-certified plastic surgeon and a breast-dedicated surgical oncologist can clarify some of those finer details. I recommend not making an emotional, hasty decision and rushing to surgery, rather hear your options, learn about your individual risk, and get additional screening — if you have dense breasts, either whole-breast screening ultrasound or MRI will be helpful to get more information!
Best, -Dr. Kapoor
Hi there.
I had sub total hysterectomy 5 years ago due to ovarian cancer. I have been on HRT since then. I am 36yrs old. I recently went for my first mammogram a few weeks ago. After doing the xray 4 times results showed that i have hetregeneous dense breast in my left.
With my history, would you advise a lumpectomy or mastectomy?
Thank you
Every women has a unique set of breast cancer risk factors. With your history of ovarian cancer, I suggest you speak to a doctor to explore if genetic testing is advised so you can learn more about any inherited risks of cancer you may have. Dense breast tissue alone is not an indication for breast surgery, and even with a cancer diagnosis, lumpectomy can be performed safely (see my article: Kapoor NS, et al. Should breast density influence patient selection for breast conserving surgery? Ann Surg Oncol. 2013; 20:600-6). There are many variables to consider.
Please feel free to contact my office if you would like to schedule a consultation. Best of luck. -Dr. Nimmi Kapoor
Hi There,
I am very super concerned I had a lumpectomy back on 2010 it was benign but I went to a mammogram on Feb. 2014 they said I have a intensive density mass on my left breast, now I just went today to do another mammogram and they told me the same thing that I still have a high visual density mass on both of my breast. Please help my PCP says that he recommends me to do a mastectomy to prevent any breast cancer in the future
Your concern is certainly understandable. Making a decision regarding preventive surgery is always difficult. Numerous factors, including breast density, can affect your risk for breast cancer. Supplemental screening with MRI or ultrasound and genetic testing is appropriate for some patients. These tests can reveal additional risk factors. We encourage all of our patients to ask as many questions and gather as much information as possible to empower themselves and become comfortable with their decision.
We would be happy to answer any questions you have and discuss your current situation, as well as your options. If you would like to schedule a consultation, please call our Orange office at 714-541-0101.
Best, Dr. Nimmi Kapoor
I am a 65 year old woman who is on HRT and has heterogeneously.dense breast. In view of how much breast density increases the chance for breast cancer, should I consider having a prophylactic mastectomy? My grandmother had a double mastectomy for BC over a 10-year period so there is also some family history. Thank you for raising the concern about breast density.
Hi Lyndsey,
Thank you for your comments and concerns. Having dense breasts is normal, and approximately 50% of women will have dense breasts. While having increased breast density can increase a woman’s chance for developing breast cancer, breast density alone does not warrant surgery for prevention. The take-away message is that screening women with dense breasts is more complicated than for women with non-dense breasts. Depending on a woman’s personal risk, including family history, either 3-D mammography, screening breast ultrasound, or MRI may be warranted. Talk to your doctor for specific recommendations about your personal risk and what is right for you.
In good health, Dr. Nimmi Kapoor
If people decide to get a mastectomy because of histiry and dense breast tissue, do they have the option to have implants put in?
Hello, thank you for your question.
Dense breast tissue alone will not be enough to warrant a mastectomy. In the event that your physician does recommend a mastectomy, there are a couple of Federal Laws that support breast reconstruction. The Women’s Health and Cancer Rights Act (WHCRA) protects women with breast cancer who choose to have their breast reconstructed after a mastectomy. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. The 1998 Federal Breast Reconstruction Law requires all health insurance companies to cover reconstruction of the breast on which mastectomy has been performed, and surgery and reconstruction of the other breast to produce a symmetrical appearance. For more information on your personal risk for breast cancer, please feel free to contact one of our offices to schedule an appointment for our Risk Assessment Program.
I have dense breast tissue and two years ago an ultrasound found one cyst and two solid masses, that together, form one complex mass. One of the solid masses measures 3cm. I had a needle biopsy that came back benign and have continued to have ultrasounds every six months. During my last ultrasound the 3cm mass had grown by 3-4mm. I went back to my breast specialist and she sent me for 3D mammogram and to a surgeon. The radiologist who did the ultrasound said, “Well, even though I can tell you it’s nothing, I think you should have it removed.” The surgeon said the same thing and the 3D mammogram radiologist said, “Well, it does seem to have regular borders, you could have another needle biopsy.” My biggest issues are that I have been doing nonprofit work in India for the last six years and going back to Italy, where I am covered on social medicine because I have an Italian spouse, for all of these tests and for the original mammogram and ultrasound when the lumps were discovered. Because I have not been living in the US I don’t carry health insurance here. I am scheduled to have the lumps removed at the day surgery hospital in Italy, under local anesthesia, in early October, for free (social medicine). Although I am American, I do speak fluent Italian, but communicating clearly about a medical situation has not been easy. And I can’t seem to get a clear consensus. I am in the US for two weeks right now and am trying to decide if I need to get another opinion here. I really don’t want to get cut but also don’t know how to understand if the surgery is really necessary. I have my ultrasound photos and one image from the 3D mammogram but all of the writing is in Italian. I have two maternal aunts that have had similar breast issues but are still alive. I have no sisters and my mother does not have any remarkable breast issues. I started my period at 13, I am 49 years old, in good health and have no children. Any suggestions?
Thank you for reaching out. That does sound quite complex and would be difficult to advise without a full physical exam. Sometimes breast MRIs can help further guide surgical decisions. In general, we do recommend excision of masses that are growing, however a close, 6-month follow-up exam would be another choice depending on all the circumstances. Talk to your doctor about specific recommendations and what is right for you. I hope this helps, best of luck.
Hello,
My mammogram last year, stated that I have Very dense breasts.
I also have saline breast implants (about 11 years).
Is there any correlation with having breast implants and very dense breasts.
Do breast implants cause dense breasts?
Thank you!
Jackie
Hi Jackie,
Breast implants do not cause or are in any way associated with dense breasts. There is no evidence that breast implants can cause breast cancer. Women with extremely dense breast should consider yearly whole breast screening ultrasounds to detect small cancers missed on the mammogram. High risk women (women with a strong family history of breast or ovarian cancer) should consider yearly screening MRI in addition to yearly screening mammograms.
John West MD (Author Prevent, Survive Thrive: every woman’s guide to optimal breast care).
I’m choosing nipple-sparing mastectomy because my breasts are classified as >75% dense and my breasts have numerous cysts/adenomas (one just below the mass is 2.4 cm & has been aspirated twice but recurs). My prior 3D mammogram was done 3 months before diagnosis and was not seen to be abnormal. My only symptom at onset was a red, painful nipple, which was unsuccessfully treated with antibiotics. The nipple did not resolve, though it seemed to subside of & on. The breast was also painful, but I believed it to be the largest cyst that had been aspirated. Because of the nipple, I asked for referral to a breast specialist, sonogram was questionable but not 100% conclusive so was referred to MRI. MRI showed a 9 mm persistent enhancing lesion near the cyst, which had border enhancement consistent with an inflamed cyst. I had a look-again sonogram/mammogram which correlated. The mammogram showed architectural distortion & a sterotactic biopsy was performed, which came back malignant, stage 1 invasive ductal carcinoma. This would not have been discovered if I hadn’t been very persistent in regard to the nipple redness, which looked benign to my doctors. With the fact of clear 3D mammograms 3 months prior & the difficulty in seeing the malignancy due to density & cysts, I do not feel confident that a recurrence would be caught early. My decision was based on the unreliability of imaging in my case and I’d never second guess anyone with extreme density and multiple cysts making the same decision.