Diagnostic Radiologist Carol Lee Discusses What Women Should Know about Breast Density

By Media Staff,

Wednesday, January 30, 2013

A patient receives a mammogram, which can determine if she has dense breast tissue
Summary

A New York State law that went into effect this month requires radiologists to inform women if they have dense breasts. Dr. Lee answers questions about the concept of breast density and what women should know.

To help improve breast cancer detection and prevention, New York Governor Andrew Cuomo recently signed legislation that requires radiologists to inform women if dense breast tissue is found on a mammogram. The law, which went into effect this month, is raising awareness among women about this topic.

In an interview, we discussed the concept of breast density with diagnostic radiologist Carol H. Lee. Dr. Lee suggests that if you find out you have dense breasts, you should discuss potential next steps with your doctor. Each individual woman’s risk for breast cancer is different, and many factors – such as family history and lifestyle – must be taken into account when determining whether additional forms of breast cancer screening are necessary.

What are dense breasts?

Breasts are made up of different types of tissue: fatty, fibrous, and glandular. Fibrous and glandular tissues appear as white on a mammogram and fatty tissue shows up as dark. If most of the tissue on a mammogram is fibrous and/or glandular, the breasts are considered to be dense.

Because cancer cells also appear as white on a mammogram, it may be harder to identify the disease on a mammogram in women with dense breasts.

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How common are dense breasts?

Breast density is classified into one of four categories, ranging from almost entirely fatty (level 1) to extremely dense (level 4). Dense breasts are completely normal. About half of all women have breasts that fall into the dense category (levels 3 and 4). Dense breasts tend to be more common in younger women and in women with smaller breasts, but anyone – regardless of age or breast size – can have dense breasts.

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How does a woman know she has dense breasts?

The only way to determine whether a woman has dense breasts is with a mammogram. A breast exam cannot reliably tell whether a breast is dense.

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What does having dense breasts do to a woman’s risk for breast cancer?

If you compare the 10 percent of women who have extremely dense breasts with the 10 percent of women who have very little breast density, the risk for breast cancer is higher in those with very dense breasts.

However, most women fall somewhere in between in terms of breast density, so it’s nearly impossible to determine whether a particular woman’s breast density is a risk factor for the disease.

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What should women who are told they have dense breasts do?

Women found to have dense breasts should talk to their doctors about their individual risk for breast cancer and together decide whether additional screening makes sense.

Tests such as ultrasound or MRI can pick up some cancers that may be missed on a mammogram, but these methods also have disadvantages. Because they are highly sensitive, they may give a false-positive reading, resulting in the need for additional testing or biopsy that turns out to be unnecessary. There is also no evidence to show that using screening tests other than mammography in women with dense breasts decreases the risk of death from breast cancer.

Ultimately, women who have dense breasts should weigh the pros and cons of additional screening with their doctor.

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Should women who do not have dense breasts make any changes to their regular screenings?

Women who do not have dense breasts may still develop breast cancer, and should continue to receive regular mammograms. Regular mammography is the only screening method that has been shown to decrease deaths from breast cancer, and all women of appropriate age should have mammograms, regardless of their breast density.

Memorial Sloan Kettering provides comprehensive, individualized breast cancer screening services that include mammography, ultrasound, and MRI, at our Evelyn H. Lauder Breast Center.

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Comments

Roselle, we are not able to answer individual medical questions on our blog. We recommend that you speak with your doctor about this. You might also find it useful to call the National Cancer Institute's Cancer Information Service at 800-4CANCER. Thank you for your comment.

My wife had her yearly mammogram and found she had dense tissue is on her breasts. Both her mother and her aunt have also had the same condition. She was sent for another mammogram and it was confirmed that she did have dense cells. She was told that the dense cells were off to the side and not under the nipple where she was told was normal. The recommendation is to remove the dense cell and put in a marker so that follow on xrays can identify where the dense tissue was removed. I did not see any recommendations when searching on-line for information that suggest removing dense tissue nor did I see anything about leaving a marker in her breast. Is this usual or should she ask for additional opinions?

Hi Rick, we are not able to provide individual medical advice on our blog. You might want to call the National Cancer Institute's Cancer Information Service at 800-4CANCER to ask more about this. If your wife would like to make an appointment for a second opinion at MSK, one of you can call 800-525-2225. Thank you for your comment.

I have been having pain in one breast for 2 months, area close to nipple. It's not getting worse or better. Went to my doctor who referred me for a diagnostic mammogram and possibly an ultrasound. They only did a mammogram. When I went back to my doctor for results he said it was normal, with moderate density in both breast. He said there was no need for anything else, just mammogram every 2 years and come back if anything changes. When reading about tissue density should I be concerned about "moderate "density, in combination with pain in only one breast that's not changing? I also had a hysterectomy 2 years ago for complex ovation cysts ( several, odd composition. Not malignant.

Dear Lynn, we are unable to answer personal medical questions on the blog. If you would like to make an appointment with one of our specialists for a second opinion, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

Is it possible for breast cancer to metastasize to other areas such as bone around your ribs? And could this cause pain in those areas?

Faith, we are not able to provide medical advice or diagnoses on our blog, but in general, yes, it is possible for breast cancer to metastasize to the bone. If you would like to make an appointment to speak with a Memorial Sloan Kettering doctor, you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

Would having breast implants make diagnosis of breast cancer in dense breasts more difficult?

Diane, we consulted with Dr. Lee on your question and she responds:

Depending on how much breast tissue is present and where the implants are placed (behind or in front of the chest muscle), the presence of implants can make a mammogram more difficult to read. All women with implants regardless of what type and where they are need at least two extra pictures of each breast in order to see as much breast tissue as possible.

I am so confused I had a breast exam at our local mammogram office, but I don't understand the results. My breast density classification is fatty. What does this mean the answers on line just have me more confused? Please give me a simple explanation.

Dear Peggy, according to our expert, Nancy Lee, breasts are made up of different types of tissue: fatty, fibrous, and glandular. And breast density is classified into one of four categories, ranging from almost entirely fatty (level 1) to extremely dense (level 4). Fibrous and glandular tissues appear as white on a mammogram and fatty tissue shows up as dark. If most of the tissue on a mammogram is fibrous and/or glandular, the breasts are considered to be dense. Because cancer cells also appear as white on a mammogram, it may be harder to identify the disease on a mammogram in women with dense breasts.

Hope this is helpful.

Is it normal or common for breast tissue density to change in time say from one year to the next? Does breast density stay the same throughout the lifetime or after menpause stay the same?
aside from cancer what are factors that can cause changes?

km, thank you for your comment. We consulted with Dr. Lee on your questions and she responds:

It is common for breast density to decrease gradually with age. However, many women maintain the same breast density throughout their lives and it is not possible to predict how any individual’s breast density may or may not change. Many things can affect breast density such as taking or stopping hormone replacement medicines or gaining or losing weight but again, this is very variable and not all women will have a change.

What other factors can cause a increase in breast density aside from taking/stopping hormone replacement and weight gain/loss?
Can cholesterol and high blood pressure medication also cause possible increases in breast density?

Dear km, as Dr. Lee pointed out, it is not possible to predict how any individual’s breast density may or may not change. We encourage you to discuss these questions with your physician, who can provide a more personalized response for you. Thank you for your comment.

Actually it is a not a personal question nor do I go to western physicians. I am trying to understand what other factors you alluded to, aside from weight change and hormonal medications, can affect changes in breast density become denser? could you please comment on that. Thank you.

Can you please tell me what a change in density from last mammogram could mean?

Dear Chrisie, we reached out to Dr. Lee for a previous similar question, and she had responded: "It is common for breast density to decrease gradually with age. . . . many things can affect breast density such as taking or stopping hormone replacement medicines or gaining or losing weight." You may want to reach out to your personal physician for a better understanding of your personal situation. Thanks so much for your question.

Dense Breast - What is Nodular Breast Tissue?

Dear Lillie, thanks so much for your question. We suggest you call cancer.gov/800-4CANCER to learn more. You may also want to look up fibrocystic breasts, or speak to your doctor to learn more about what it means for you or your loved one. Thanks again for reaching out to us!

I am wondering if a digital mammogram shows extremely dense breasts but is normal should additional testing be recommended to the patient.

Vicki, thank you for reaching out. These types of personal medical decisions are best discussed with your physician. As Dr. Lee stated in one of her answers:

"Women found to have dense breasts should talk to their doctors about their individual risk for breast cancer and together decide whether additional screening makes sense.

Tests such as ultrasound or MRI can pick up some cancers that may be missed on a mammogram, but these methods also have disadvantages. Because they are highly sensitive, they may give a false-positive reading, resulting in the need for additional testing or biopsy that turns out to be unnecessary. There is also no evidence to show that using screening tests other than mammography in women with dense breasts decreases the risk of death from breast cancer.

Ultimately, women who have dense breasts should weigh the pros and cons of additional screening with their doctor."

I really do not see the benefit from posting questions/comments on this site. The answer more often then not is that you cannot answer medical questions. There appears to be a lot of women that fear breast cancer (including myself) and it seems that answering their concerns would be helpful to them (rather then blowing off their questions)

I have been having breast pain on my left breast. What do you suggest I do next?

Dear Virginia, we are sorry to hear you are not feeling well. We encourage you to contact your physician to discuss your symptoms and receive appropriate follow up. Thank you for reaching out to us.

What is the point of a mammogram if you have extremely dense breasts. I am having an ultrasound on them but they say must have another mamogram first. I dont see the point since they said they couldnt see anything last time it was too dense. Seems like they just want more money.

Allison, we sent your questions to Dr. Maxine Jochelson, Director of Radiology at our Breast and Imaging Center, and she replied, "Mammography is the ONLY breast imaging examination that has been proven to reduce the mortality from breast cancer. Mammography has the ability to detect cancers within the breast that may not be detected by ultrasound. In particular, many cancers present with calcifications and these are primarily picked up on mammography and not ultrasound. Ultrasound and mammography are complementary. Doing ultrasound alone would decrease the ability to detect cancers even in dense breasts." Thank you for your comment.

I wish I had known about the risk of dense breasts and breast cancer before I was diagnosed last year with Stage 4 breast cancer. It is being fed by high hormones, and through the use of anti hormone medication and Xgeva, my cancer has been dormant since February.

I grew up in a place where cancer was not a common condition. I did not know the seriousness of cancer as there was no awareness being raised especially for younger women. I developed sores on my back and breasts which were terrible they ruined my skin, the sores on healed after cream application but i did not see doctor as i did not know the importance and danger. They left scars, on one of the breasts the scars are like a pattern they are next to each other maybe 1cm apart going around the breast like they were each from a duct or lobule. This happened 7 years ago, recently I had breast pain inside breasts and visited the doctor i was referred for mammo and ultra and told im fine yet i was dying with pain. Only to further discover that I am end stage bc with mets to liver bone spine and brain. Cancer is all over they say so im on pain mgt waiting for time. It pains me to think that had I known about bc i would have investigated years back and maybe got treatment and added further years of life. Only a miracle will save me

Thank you for sharing your story. We are very sorry to hear about your diagnosis.

Please comment on 3-d mammograms for women with dense breasts. Would this test replace ultrasound and mri?

Thank you for reaching out. Dr. Lee was asked about 3D mammography by another reader and responded: "The experience with tomosynthesis (the actual name of the so-called 3D mammograms) is still early. Some studies have shown a better cancer detection rate but others have not compared it with the regular digital mammogram. All of the studies so far do show a decrease in false-positive readings with tomosynthesis."

You also may be interested in this follow-up Q & A with Dr. Lee on breast density:

https://www.mskcc.org/blog/diagnostic-radiologist-carol-lee-give-more-i…

I recently had a digital screening mammogram. I got the results back saying my breast were heterogeneous dense. What is the meaning of heterogeneous dense?

Cheryl, thank you for your question. Heterogeneously dense indicates that there are some areas of nondense tissue, but that the majority of the breast tissue is dense.

I had a mammo and ultrasound test in July. They did 5 images on each breast for the mammo. Also, they did the ultrasound. They told me that my cyst is too small to biopsy. I also have hetergenous breasts too. The size of the cyst is 0.4 x 0.2 x 0.4. They told me to come back in 1 year. I begged for 6 months and they said no. Should I get another ultrasound or MRI to see if the cyst has grown? Or skip those tests and get the 3D test.

With a palpable lump, yet negative mammogram, ultrasound, and MRI, in a postmenopausal woman, would a second opinion or biopsy be a logical next step, as opposed to waiting?

Ellen, thank you for your comment. We are unfortunately unable to offer specific advice reagarding medical questions as every patient is different. We recommend you consult with your personal physician (or seek a second opinion if that is your personal decision).

About 3 weeks ago I had a outbreak of a rash and bruising on my left breast with peeling. Was given antibiotics that help clear it up. My doc request for me to get a mammogram which was my very first one that came back extremely dense! But my question is can a biopsy be done before any more test since that is what confirm if it is cancer?

Holly, we understand that you are anxious about this, but a biopsy is not usually done until other screening tests, such as ultrasounds, are done first. Thank you for your comment, and best wishes to you.

For the past years, I'd been getting letters that I have dense breast. During my annual mammogram this morning, I was asked if I wanted to have the 3D mammogram for an out of pocket cost of $65 (discounted as I am a hospital employee) I agreed because of my dense breast. After 3 hours, I got a call from our nurse that I needed to be re-tested: mammogram and ultrasound scheduled next week. My question is, isn't it that 3D mammos can capture better pictures than the regular mammogram? I feel like I just wasted $65 on the 3D when I could've just used the regular mammogram. Then if re-tested is needed, ultrasound will be the next option.

Chrissy, thank you for your question. We suggest you consult with your treatment team about their decision process regarding which imaging method was used.

Some studies have shown a better cancer detection rate with tomosynthesis (the actual name of the so-called 3D mammograms) but others have not compared it with the regular digital mammogram. All of the studies so far do show a decrease in false-positive readings with tomosynthesis.

You also may be interested in this follow-up Q & A with Dr. Lee on breast density:

https://www.mskcc.org/blog/diagnostic-radiologist-carol-lee-give-more-i…

I know mammogram and ultrasound is a twin procedure. I am 25 years old with a strong family hx of Breast cancer. I did a baseline mammogram when I was 22 and did ultrasound for the next years. This year, they had been calling me about doing a mammogram even after a benign result on ultrasound. I have a dense breast and having radiation procedure at my age is risky. Should MRI be the next step and skip mammogram?

Dear Jasmine, your physician is the best person to offer specific recommendations on what tests, such as MRI, would be appropriate for you. If you would like to make an appointment with a specialist in our screening program for women at high risk for breast cancer, please call 646-497-9064. More information about the program and its services is available here: https://www.mskcc.org/cancer-care/risk-assessment-screening/screening/i….

Also, your concerns about radiation are not uncommon. It's most important to have a discussion with your doctor about the risks and benefits of having the test. He or she may believe that the benefits of finding a possible cancer outweigh any small risk that may exist by having another mammogram. You may find it helpful to learn more by reading our blog on scan safety here: https://www.mskcc.org/blog/scan-safety-radiation-reality-check.

Thank you for reaching out to us.

If a diagnostic mammo returns with a birad 4 n the ultrasound a birad 2. Which test determines if biopsy is needed the mammo or ultrasound or both?

Isabel, thank you for reaching out.

We consulted with MSK radiologist Maxine Jochelson, who responds:

"The ultrasound BIRADs 4 determines that a biopsy is necessary."

Thank you for your question.

Can Dr Lee tell us what the normal range of pressure applied by the mammogram machine is, and if that range differs for postmenopausal women? I'm referring to what I believe are the paddles that use pressure to hold the breast in place during the exam mammogram. Thank you.

Emily, we sent your question to Maxine Jochelson, Director of Radiology at our Breast and Imaging Center, and she replied that during mammograms, the breast is compressed as much as the patient tolerates. The degree of compression is based on the individual breast and not menopausal status. Thank you for your comment.

Is it possible for an abnormal finding on a diagnostic mammogram to not show up on a follow up ultrasound?

Anette, we sent your question to Maxine Jochelson, Director of Radiology at our Breast and Imaging Center, and she replied that it is possible for mammographic findings to not show up on an ultrasound and in fact calcifications -- a common presentation for cancer -- often do not. That is why ultrasound is considered a supplemental exam and not the primary screening exam. Thank you for your question.

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