ongoing debate on the cancer front is whether doctors should
be required to notify women following mammograms if they have
dense breast tissue, which can fool the screening test and
miss tumors. Minnesota recently became the latest state to
create the mandate, prompting a new round of debate.
the Minnesota mandate, the standard "all-clear"
letter sent after mammograms to tell women they are
cancer-free is going to contain new and potentially troubling
information — the disclosure to thousands of women that they
have dense tissue in their breasts that could cloud their
lawmakers mandated as of Aug. 1 that doctors notify women if
their mammograms discover dense breast tissue, which can mask
the presence of a tumor on an X-ray like blowing snow can
blind a driver in a blizzard.
is no shortage of women like me who have been harmed by their
density and never knew it," said Nancy Cappello, a breast
cancer survivor from Connecticut. She became an advocate for
state-mandated disclosure of tissue density after mammograms
failed to find her tumor until it was enlarged and her cancer
had spread beyond her breast.
tissue density is well-known among cancer specialists and
radiologists; studies suggest 47 percent of women have tissue
that is dense enough to hide a tumor on an X-ray image.
Research also has indicated that dense breast tissue itself
increases cancer risks, especially for the 8 percent of women
with extremely dense tissue.
doctors treat tissue density as back-of-the-house information
that patients don’t need to know, in part because it is
unclear exactly what women should do with the information and
which alternative cancer screenings work best.
said doctors were so resistant to notifying patients on their
own that she formed the "Are You Dense?" advocacy
organization and sought mandates that have been enacted in 19
was shocked," she said, "not that I had breast
cancer, but that it was (detected) so darn late."
mandate proposals have generated intense debates in other
states, the Minnesota legislation quietly received support in
the House this spring before it was tucked into a health care
omnibus bill and sent to the governor’s desk. Organizations
such as the Minnesota Medical Association had concerns —
especially the impact of notifying so many women when the
solutions for dealing with dense breast tissue are unclear —
but didn’t oppose the bill.
Norton of the Minnesota Breast Cancer Coalition suspects the
lack of opposition was due to a "pink tsunami" of
high-profile breast cancer advocacy campaigns, which make it
politically difficult to oppose an increase in screening even
if it might lead to more incidents of misdiagnosis and
opposed the mandate because there is no scientific proof yet
that supplemental screening beyond mammography reduces the
rate of breast cancer deaths. Diet and alcohol consumption are
known risk factors for breast cancer, but they might not
receive as much emphasis if doctors are busy explaining breast
tissue density to patients, she added.
women get notification that they’re overweight? It also is a
risk factor. And that’s something a woman can change,"
fraction of women with dense tissue suffer breast cancer. Some
women, when told, ignore it or simply increase the frequency
of manual self-exams, Norton said. Others stop taking hormone
replacements because of evidence that it increases breast
alternatives include ultrasound imaging or a special 3-D
ultrasound called digital breast tomosynthesis, which has been
shown to increase breast cancer diagnoses while reducing false
positive results. Women with family histories of breast cancer
are supposed to seek more accurate MRI scans, but they are not
recommended for other women.
national guidelines exist on which approaches to use. The U.S.
Preventive Services Task Force is examining breast tissue
density as it updates its guidance on breast cancer screening,
but new guidance isn’t expected for months.
force currently recommends mammograms every other year for
women ages 50 to 74, and screenings at earlier ages depending
on family cancer histories.
over screening alternatives shouldn’t excuse doctors from
their responsibility to notify patients of tissue density,
Lewerenz, a 57-year-old attorney from Duluth, said her tissue
density fooled mammograms to the point that a tumor in her
breast was the size of a lemon before it was discovered in
opportunity to talk to my physician about what it meant to
have dense breasts could have been important to me," said
Lewerenz, who will forever wonder if earlier detection could
have meant treating the cancer with a simple removal procedure
rather than multiple surgeries, chemotherapy and radiation.
question regarding the mandate is whether insurers will cover
alternative screenings for women with dense tissue.
Cross and Blue Shield of Minnesota, the state’s largest
insurer, doesn’t have a policy but "works closely with
providers and supports their judgment for when additional
evidence-based imaging studies may be necessary," said
Dr. Paul Krazija, Blue Cross’ vice president and executive
medical director for commercial and government programs.
with mammogram results started going out from Mayo Clinic this
month with information on tissue density. The response has
been so mild that the clinic’s director, Dr. Karthik Ghosh,
wonders if women are reading beyond the first sentence
indicating a negative test result.
know what happens with those letters," she said.
said mammograms are 88 percent accurate for women with little
tissue density but still 62 percent accurate for women with
extreme density, so women should continue to undergo testing.
On the other hand, she noted, women shouldn’t dismiss lumps
in their breasts just because their mammograms were negative.