Early Detection Alert: The Risk of Being "Too Young for a Mammogram"

A major concern is the presence of breast cancer in underserved communities, including those TOO YOUNG FOR A MAMMOGRAM.  Whereby the medical community touts the recommended (and legal/billable status) of getting a mammo scan should be between 40-50, what happens to the many women who do not fit this age criteria?  How would they even know to get checked without the support of their clinicians or an alarm from family history?

Decades into the battle against breast cancer, clinicians and the public are much more educated about EARLY DETECTION, PREVENTION and the current protocols and modalities available to save lives.  Recent headlines on DENSE BREAST and the advancements in ULTRASOUND SCANNING supports a major part of this battle.

WHAT ABOUT IF YOU'RE TOO YOUNG FOR A MAMMOGRAM?   I went to my doctor for a lump I felt in my breast and she gave me a response that set off red flags: "don't worry about it". Being a researcher involved in breast density and breast cancer, I knew that I had to take action; I was fortunate enough to have my breast ultrasound training with Dr. Robert Bard (cancer imaging specialist, NYC) upcoming in the next week. Dr. Bard showed me how to use the ultrasound to help me find two benign tumors in my breasts, and it was there that he reported that I have dense breasts. Had I not taken action in getting screened at the young age of 22, I would have never known that I should be getting screened via ultrasound every 6 months (because having dense breasts puts me at a higher risk for breast cancer), nor would I have known that I had benign breast tumors. 

- ALEXANDRA FIEDERLEIN, 22

Cancer Researcher/ Graduate- Molloy Univ.

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UNDERSERVED AGE FOR EARLY DETECTION

By Dr. Robert L. Bard and Joe Cappello of AreYouDense.org

Doppler Sonography offers clinical accuracy and access
to breast imaging evaluation (www.breastcancernyc.com)

According to Breastcancer.org, "Where mammography is available, ultrasound should be seen as a supplemental test for women with dense breasts who do not meet high-risk criteria for screening [with] MRI and for high-risk women with dense breasts who are unable to tolerate MRI... but if mammography isn’t available, then ultrasound seems to be a good alternative for breast cancer screening."

A recent cohort study is underway under a partnership between Molloy College and AreYouDense.org  to publish new findings about low BMI patients and younger women about the presence of dense breast tissue.  This same review also covers the advantages of ultrasound use where mammography is not available.

Mammography is the current standard for breast cancer early detection for women 40 & older. Recent studies have shown nearly half of all women who get mammograms are found to have dense breasts, exposing this population to the risk that mammograms may miss potentially cancerous tumors concealed by dense breast tissue.  Dr. Cutter's initial concepts to target LOW BMI (bet 12-22% body fat) was personally inspired.  As an active TRIATHLETE, her own diagnosis sparked her survey and inquiry throughout the athletic community where she uncovered a significant trend that became the basis for this research. She wishes to target younger women, athletes and members of underserved communities. "Younger women may be more likely to have dense breasts... also I find athletes with LOWER BMI (body mass index) or those with  less body fat are more likely to have more dense breast tissue compared with women who are obese." (See complete feature article)

IN THE NEWS: DENSE BREAST PARADIGM NEVER FORGET: NANCY CAPPELLO 10/23/2023 - In celebration of the upcoming birthday of the late Dr. Nancy Cappello (Oct. 30), the ICRS (Integrative Cancer resource Society) gives honor to her courage and life-saving pursuits to bring global awareness about the risks of Breast Cancer from the link to dense breast tissue.  Dr. Cappello’s work to inform women about the risks of dense breast tissue led to density inform laws in 35 states.  According to Dr. Roberta Kline (Women's Health Digest medical publisher) and Dr. Leslie Valle- Montoya (ICRS exec. director), "...though we all know her passing to earmark a major movement in women's health, honoring the birthdate of such a figure posthumously (we feel) better resonates a more loving and eternal remembrance of message by breathing continued life to her legacy!" She was recognized throughout the women's cancer community as the founder of the breast density education movement in the U.S., on her passing on Nov. 15. A breast cancer survivor herself, Cappello passed away from secondary myelodyspastic syndrome (MDS), a bone marrow cancer that was a complication of her prior aggressive breast cancer treatments. Cappello was diagnosed with stage 3C breast cancer in February 2004, just six weeks after her annual mammogram came up normal. Her doctor told her that the cancer was missed on the mammogram because she had dense fibroglandular breast tissue, a concept that was little-known among patients at that time. Dense breast tissue appears white on a traditional 2-D mammogram, which can mask cancers that also show up as white. Women with extremely dense breast tissue are five times more likely to have breast cancer compared to women with fatty breasts.  (See original source: ITN NEWS) From the newsletter of: The cancer research front and patient care community continues to pursue further awareness of dense breast diagnostic updates.  This includes the sensible use of ultrasound imaging as a supplement to mammography.  Dr, Cappello's mission included bringing change to the patient health care community by 'insisting' on the use of ultrasound as a supplement to mammogram because of its ability to detect cancer (tumor) presence by its ability to see through the cloudy obstruction of breast tissue density. "Hybrid imaging refers to combining diagnostic modalities to assess disease and monitor therapy. A useful combination of options is identifying the tumor vessel flow density to assess aggression and treatment progress. Similarly, tissue elastography is useful for border detection of malignant masses", says Dr. Robert Bard of the Bard Cancer Center, NYC. Click to see NEWS The DENSE BREAST TISSUE / CANCER CONNECTION is a topic that has finally achieved proper recognition in our community. Thanks to organizations like The 'ARE YOU DENSE?' Foundation, awareness of this health concern has now shed light to the risk to 40+% of the national women's population whereby more clinicians are now recognizing the need to state a patient's dense breast status.  Research crusaders like  Dr. Noelle Cutter and research associate Alexandra Fiederlein from Molloy University are underway the 2022 National Survey of Dense Breast Studies by bringing ultrasound access to underserved members of the women's community.  In a recent episode of SPOTLIGHT ON AMERICA, Dr. Bard spoke as the clinical expert in the report "Millions of women have this breast cancer risk factors... why aren't they being informed?" -- TND REPORT/Spotlight on America is pressing to ensure women have access to a crucial health fact that could save their lives. According to the Centers for Disease Control and Prevention, 40% of women have dense breast tissue, which is a risk factor for cancer. The TND team first highlighted this issue in October 2021, and more than a year later, we expose how some women are still being left in the dark about their density, and federal health bodies are failing to make sure they’re informed.

REVIEW ON WOMEN'S EARLY DETECTION STANDARDS 

Excerpt from the 2021 NYCRA Dense Breast Diagnostic Conference By: Dr. Roberta Kline

Breast cancer is still one of the most common cancers in women, and the leading cause of cancer mortality. While mammography is considered the standard imaging for early detection, it falls short for many – including those with dense breasts. Approximately 40% of women have dense breasts, which we now know is associated with an increased risk of breast cancer. On top of this increased risk, mammogram is less sensitive for early detection – up to 50% less for women with the highest breast density. [1] As a result many women are not diagnosed until they have a much later stage cancer – and a worse prognosis. [2]

The State of Connecticut passed legislation requiring notification of breast density in 2009, after having passed legislation requiring insurance coverage for ultrasound for dense breasts in 2005. As an ObGyn physician practicing in CT at the time, I remember the discussions with colleagues and patients around this issue although at the time there were no formal efforts to raise awareness or update guidelines from our national specialty organization, the American College of Obstetricians and Gynecologists (ACOG). 

PERSPECTIVE: PERSONAL FINDINGS BY A CLINICAL PROFESSIONAL

I was fortunate to have benefited personally from this effort when I had my first screening mammogram shortly after the law went into effect. The reading radiologist personally informed me of my high breast density immediately after the mammogram, and after recommending a breast ultrasound for further evaluation this was done right then and there. I walked away from my appointment feeling well informed, and any potential anxiety relieved by the prompt additional imaging and results. I also knew that I needed a different approach for my screenings going forward.

Between 2009 and 2019, 37 other states and D.C. passed legislation requiring notification of breast density, one of the last being my new home state of New Mexico. In 2019 a federal law was passed to require both clinician and patient reports contain plain language around the woman’s breast density, and to discuss with her provider. The FDA then created standard language that has now been implemented, requiring reporting on a woman’s individual breast density, and recommendation to discuss with her provider.

There is still much to be learned about what causes dense breasts and why women with dense breasts have an increased risk of breast cancer, and our ongoing study is one of many that are seeking to answer these questions at the molecular and genetic level. But the evidence that supplementing mammograms with other imaging modalities can increase the rate of early detection is substantial, and provides us with tools we can use right now to make a difference. [3,4]  Despite this progress, there are still significant hurdles in changing the standard of care. A recent experience with my routine breast cancer screening highlighted the ongoing challenges. When I had asked to schedule an ultrasound with my screening mammogram, I was informed that it was not done this way – I could only get a mammogram. After my mammogram, I had to wait to receive my letter in the mail approximately one week later to be able to take any additional steps. The interpretation included a description of breast density and recommended to discuss any additional care with my physician. 

When I called to schedule an ultrasound, I was told that since the radiologist did not recommend it in the report, I could not schedule it. I then had to speak with my primary care provider, educating her on dense breasts and why I needed an ultrasound. Luckily, she agreed to order one. While the radiology facility still questioned the order, eventually I was able to have this done. When the radiologist came in to discuss my results, she too was confused as to why I was having the ultrasound, and was not aware that this should be standard for women with dense breasts.

See 2022 Dense Breast Ultrasound Study

Fortunately all was fine, but had I not been a physician that was fully aware of this issue, I would very likely have had only a mammogram and walked away with a dangerously false sense of security. This experience highlighted for me how much still needed to be done more than 20 years after my first experience. Legislation is only part of the solution. Clinician education and public awareness are the keys to changing how the intention behind these laws gets translated into actual change in health care.

As I experienced, many clinicians are ill-informed about the nature of dense breasts, and options for adjunctive screening including ultrasound or MRI. This means that many of these reports end up being filed away with no further action being taken that could make a significant difference in early detection and saving lives.

EPILOGUE: CURRENT STANDARDS VS NEEDS

ACOG still officially does not recommend any further imaging for women with dense breasts on mammogram, despite the significant body of evidence suggesting that mammogram alone is insufficient and adjunctive imaging with ultrasound or MRI increases rate of early detection. [5] The U.S. Preventive Task Force [6]  does not recommend routine adjunctive imaging for screening women with dense breasts. This leaves many healthcare practitioners, from ObGyns to other primary care providers, unprepared to discuss this with their patients or provide sound recommendations. 

The American College of Radiologists, who also publishes the BIRADS standards for breast cancer screening, acknowledges awareness of breast density detection issues with mammography but stops short of recommending routine adjunctive imaging. Instead, they list ultrasound and MRI as “may be appropriate”. [7] We have enough evidence to know how to better serve women with dense breasts, and we can do better. Now we need to push for better education of all primary health care providers, including ObGyns, and continue to raise awareness for women around current knowledge and best practices. 

References

1) Gordon PB. The Impact of Dense Breasts on the Stage of Breast Cancer at Diagnosis: A Review and Options for Supplemental Screening. Curr Oncol. 2022 May 17;29(5):3595-3636.

2) Chiu, S.Y.H.; Duffy, S.; Yen, A.M.F.; Tabár, L.; Smith, R.A.; Chen, H.H. Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-Year follow-up of a Swedish mammographic screening. Cancer Epidemiol. Biomark. Prev. 2010, 19, 1219–1228

3) Harada-Shoji N, Suzuki A, Ishida T, Zheng YF, Narikawa-Shiono Y, Sato-Tadano A, Ohta R, Ohuchi N. Evaluation of Adjunctive Ultrasonography for Breast Cancer Detection Among Women Aged 40-49 Years With Varying Breast Density Undergoing Screening Mammography: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2021 Aug 2;4(8):e2121505

4) Mann, R.M., Athanasiou, A., Baltzer, P.A.T. et al. Breast cancer screening in women with extremely dense breasts recommendations of the European Society of Breast Imaging (EUSOBI). Eur Radiol 32, 4036–4045 (2022).

5) Management of Women With Dense Breasts Diagnosed by Mammography. ACOG Committee Opinion. CO Number 625 March 2015

6) https://uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening

7) American College of Radiology ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density. 2021

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