Complete List of Questions and Answers
What Is Breast Density and Why Does It Matter?
1. What are dense breasts?
“Dense breasts” are words that describe the mix of fat, milk glands/milk ducts and fibrous tissue in a breast. The more glands and fibrous tissue a woman has (also called “fibroglandular” tissue), the “denser” her breast tissue.
Each woman has a unique mix of fatty and dense tissue in her breasts. Some women have very little dense tissue compared to fatty. Other women have more dense tissue compared to fatty. Most women’s breasts are somewhere in-between.
Are Dense Breasts Normal?
Dense breasts are normal and common. Dense breasts are not caused by illness or disease. But there are some reasons for concern. That is because dense breasts can make it harder for radiologists to find cancer on a mammogram. Also, dense breasts increase a woman’s risk for breast cancer.
Here is more to know:
- Dense tissue appears as light gray or white on a mammogram (see image on the right). In dense breasts, any lump (whether due to cancer, or not) can also look light gray or white. That makes it harder for radiologists to find cancers on a mammogram for women who have dense breasts. It is like trying to find a snowball in a blizzard.
- Dense breasts are a risk factor for breast cancer. A woman’s risk for breast cancer increases with the level of density in her breast.
Video: What is Breast Density?
2. What causes dense breast tissue?
Dense breasts are normal and are not caused by illness. All breasts are made of fat, and milk ducts/milk glands held together by fibrous tissue. The glands and fibrous tissue (or “fibroglandular” tissue) are referred to as “dense tissue”.
Each woman’s breasts are different and contain their own mix of fatty and dense tissue. Some women have breasts made of mostly fatty tissue. Some women have breasts with a lot of dense tissue. The more glands and fibrous tissue that a woman has, the “denser” her breast tissue is.
How can I tell if I have dense breasts?
The radiologist (the doctor who looks at your mammogram) can tell how dense your breasts are by how they look on your mammogram. You cannot tell if you have dense breasts by the way your breasts look or feel.
3. Women often ask how to diagnose dense breast tissue. “How is breast density on a mammogram determined?”
Radiologists are the doctors who determine whether a woman has dense breasts. They do so after looking closely at images from mammograms. Radiologists may also use computer software to measure breast density. Breast density cannot be determined by how a breast looks or feels.
There are 4 categories of breast density. Here is more to know about each category:
Category A. Fatty, or almost entirely fatty breasts. This means that most of the breast is made of fat tissue. On a mammogram, a fatty breast appears as mostly dark grey or black. While most of the breast is fatty tissue, there may be a small amount of dense (fibroglandular) tissue that looks light grey or white. About 10% of all women have fatty breasts. Breasts in Category A are not considered dense.
Category B. Scattered areas of fibroglandular density. The breast has a mix of fatty tissue which appears dark grey or black, and scattered dense (fibroglandular) tissue which looks light grey or white. It can be hard for radiologists to find cancer, which often also look light grey or white, in areas that are dense. About 40% of all women have this type of breast. Breasts in Category B are not considered dense.
Category C. Heterogeneously dense breasts. Large portions of the breast are made of dense (fibroglandular) tissue. On a mammogram, the breast appears mostly light grey or white. It is harder for radiologists to find cancer, which often also looks light grey or white. About 40% of all women have heterogeneously dense breasts. Breasts in Category C are considered dense.
Category D. Extremely dense breasts. Most of the breast is made of dense (fibroglandular) tissue. On a mammogram, the breast looks almost all white. This makes it very hard for radiologists to find cancer, which often also looks light grey or white. About 10% of all women have extremely dense breasts. Breasts in Category D are considered dense.
4. How do I know the answer to the question: Are you dense?
In the U.S.A., most states now have laws that require breast density information to be included in the letter you receive after your mammogram. Even if you do not live in a state with a breast density inform law, you can ask your doctor or referring health care provider for this information. Your breast density is usually in the mammogram report sent to them. Click here to see what you must be told about breast density in your state.
In Europe, the facility that does your mammogram may either have this information or allow you to request it. Density Request forms are available for the UK here.
5. Why does breast density matter on my mammogram?
Cancers can be hidden or “masked” by dense tissue. On a mammogram, cancer is white. Normal dense tissue also appears white. If a cancer grows in an area of normal dense tissue, it can be hard or even impossible to see cancer on a mammogram.
It is like trying to see a snowball in a blizzard.
- If a cancer (white) develops in an area of fat (black or dark gray/grey), it is usually easy to see cancer even when it is small. The more fatty a breast is, the easier it is to see cancer on a mammogram.
- Dense breast tissue can hide cancers. The denser a breast is, the harder it is to see cancer on a mammogram.
Cancer on a Mammogram in a Fatty Breast vs. a Dense Breast
Learn more on this topic in our Patient Education Video series, Let’s Talk About Dense Breasts.
6. Do dense breasts affect my risk of getting breast cancer?
Yes. Dense breasts not only can hide cancer on a mammogram, but they also increase the risk of getting breast cancer. Cancers grow more often in dense tissue than in fatty tissue. The denser the breasts are, the higher the breast cancer risk. Women with the densest breasts (“extremely dense”) are 4 times more likely to get breast cancer than women with the least dense breasts (“fatty” breasts). Most women’s breasts have density in between these two categories (“scattered fibroglandular density” or “heterogeneously dense” breasts).
What are risk factors for breast cancer?
Most breast cancer occurs in women with no known risk factors other than being a woman and getting older. There are many risk factors that increase the chance of getting breast cancer. For example:
- Having dense breasts
- Having a family history of breast or ovarian cancer (particularly in your mother or sisters)
- Having an atypical breast biopsy (where breast cells from a small sample of your breast tissue were not normal, but not yet cancer)
Download, save or print this helpful Risk Checklist to discuss with your health care provider.
1. American Cancer Society. Breast Cancer Facts & Figures 2019-2020. Atlanta: American Cancer Society, Inc. 2019. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2019-2020.pdf. Accessed April 20, 2020.
2. McCormack VA, dos Santos Silva I. Breast density and parenchymal patterns as markers of breast cancer risk: A meta-analysis. Cancer Epidemiol Biomarkers Prev 2006; 15:1159-1169
7. Should I worry about dense breast tissue? Are dense breasts abnormal?
Dense breasts are normal and common. Though normal, dense breasts do increase the risk of developing breast cancer and of having a cancer missed on a mammogram.
Many women have dense breasts. Density tends to decrease as a woman gets older.
Talk to your health care provider about whether you should have additional tests after your mammogram. Click here for 5 Facts Every Woman Should Know.
What Should I Know About Dense Breasts?
8. Are dense breasts common? Is it unusual to have dense breasts?
Why do dense breasts matter?
Dense breasts matter because dense tissue can hide cancer on a mammogram. Dense breasts also increase the risk of developing breast cancer. If you have dense breasts, you may need another test in addition to your mammogram to find cancer (if present).
For more information, see “Dense Breasts: 5 Facts You Should Know”
9. Is breast size related to breast density?
Smaller breasts are more likely to be dense, and larger breasts are more likely to be fatty, but density and size both vary from person to person.
10. Is breast pain or breast tenderness related to dense breast tissue?
No. Breast pain or tenderness is not related to breast density. Breast pain that comes and goes is often because of changes in hormones due to your period and is most common on the sides of your breasts (near your arms and underarms).
Benign (not cancerous) cysts, lymph nodes, and other non-cancerous growths in your breasts may cause tenderness. Skin conditions, such as shingles, and muscle soreness, can feel like breast pain.
Does breast pain mean that I have cancer?
No, breast pain alone is rarely due to cancer. If you have a painful lump or a point of pain (that you can point to with one fingertip) that lasts several weeks, you should talk with your health care provider about having additional tests.
For more information, see Q+A, “Why does breast density matter on my mammogram?”
11. I have been told my breasts are dense. How do I find out what category they are in?
In the U.S.A., the radiologist (the doctor who looks at your mammogram) will send a report to your health care provider after your mammogram. Your breast density category (fatty, scattered density, heterogeneously dense or extremely dense) is usually in that report. Your density category may also be in the letter you receive after your mammogram. If not, you can call either the radiologist or your health care provider to find out your density. Each state has different laws about the information you must be given about your breast density. To learn what the law is in your state, click here.
In Europe, the facility that does your mammogram may either have this information or allow you to request it. Density Request forms are available for the UK – England/Wales; Scotland; Northern Ireland; Republic of Ireland here.
12. Will my breasts always be dense?
- Breasts tend to become less dense with age and menopause (see Figure below), but not always.
- Breasts become more dense (denser) during pregnancy and breast feeding. This is because the glands that make milk grow and the glands themselves are part of dense breast tissue. Breast density returns to what it was before pregnancy about 2-3 months after you stop breast feeding.
- If you lose a lot of weight, your breasts may appear denser on a mammogram because there is less fat, but the amount of dense tissue stays the same.
Breasts Can Become Less Dense with Age and Menopause
Left Image: A screening mammogram image of a premenopausal woman (age 49) shows heterogeneously dense breast tissue (Category C).
Right Image: A screening mammogram image of the same woman, now postmenopausal (age 52). Her breasts are less dense and now show scattered fibroglandular density (Category B).
13. Do I need to know my breast density before I begin getting mammograms?
No. You would not know your breast density until you start having mammograms. In the U.S.A., most medical societies recommend that women at average risk for developing breast cancer begin mammograms at age 40. European guidelines on when to begin getting a mammogram vary by country (click here for information by country).
If you have a family history of breast cancer or are found to have dense breasts, talk to your health care provider about your risk factors and about which breast cancer screening plan is right for you.
14. If I don’t have dense breasts, what should I do?
In the U.S.A., if you are age 40 or over, at average risk of developing breast cancer, and in good health, most medical societies recommend a mammogram every year (with 3D mammography/tomosynthesis, if available). If your health care provider determines that you are at high risk of getting breast cancer, a yearly MRI may be recommended to begin by age 25 to 30, with yearly mammograms beginning at age 30.
European breast cancer screening guidelines vary by country; for specific information by country, click here.
What Do I Need to Know About Mammograms and Dense Breasts?
15. What is a mammogram? Are there different types of mammograms?
Mammograms are low-dose x-rays that expose the breasts to a small amount of radiation.* Mammograms have been used to screen for breast cancer since the 1980s. There are three different types of mammograms:
- Film: 2-Dimensional, known as “analog” has been nearly eliminated in the U.S.A., but is still in use in Europe.
- Digital, 2-Dimensional: known as “Full Field Digital Mammogram” (FFDM). Nearly all facilities in the United States have digital mammography.
- Digital, 3D/tomosynthesis: also referred to as “3-Dimensional” or “tomo.” It is a newer technology that is used in over half of the facilities in the United States.
*The radiation exposure from a mammogram is small and is too low to cause any harm to the breasts.
To learn more about mammograms, including how they work, benefits and things to consider, click here.
16. Is there a chance I can have cancer even when my doctor said my mammogram was normal?
Yes. A “negative,” “benign,” or “normal” mammogram report does not mean cancer is not there. The denser the breast, the more likely it is that a cancer will not show on a mammogram.
|Category of Breast Density||Percent of Cancers That Will Not Show on a Mammogram|
Rev. March 2022
Cancer can still be there even if the mammogram report is “normal.” You may want to have an additional screening test after your mammogram to help find cancer. These tests might include one of the following: Ultrasound, MRI, contrast-enhanced mammography or molecular breast imaging (MBI). If your mammogram shows dense breasts, talk with your doctor or health care provider about whether you should have an additional screening test after your mammogram.
For more information, see Q+A, “What are screening options after my mammogram?”
1. Kerlikowske K, Zhu W, Tosteson AN, et al. Identifying women with dense breasts at high risk for interval cancer: a cohort study. Ann Intern Med 2015; 162:673-681
2. Wanders JO, Holland K, Veldhuis WB, et al. Volumetric breast density affects performance of digital screening mammography. Breast Cancer Res Treat 2017; 162:95-103
17. If mammograms miss some cancers in dense breasts, should I still have a mammogram?
Yes. Though both 2D and 3D mammograms can miss cancers in dense breasts, mammograms are still helpful. Some cancers will only be seen on a mammogram (and won’t be seen on Ultrasound or possibly even on MRI).
For example, even in dense breasts, mammograms will show calcifications (white specks like salt crystals, see Figure below), which are seen better on mammograms than on Ultrasound. About half of all breast cancers have calcifications. However, most calcifications seen on a mammogram are not due to cancer.
Many studies have shown that finding early stage cancers on a mammogram reduces deaths from breast cancer.
Mammograms Show About Half of Early Breast Cancers Even in Dense Breasts
This mammogram of a woman with dense breasts shows a group of calcifications (white specks that are like salt crystals within the red ovals). This patient was diagnosed with invasive breast cancer (“invasive” means it has spread to surrounding breast tissue).
18. I have dense breasts and cancer might be missed on my mammogram. What else can I do?
For women with dense breasts, an additional breast screening test after a mammogram may find cancer not seen on the mammogram alone. There are benefits and things to consider when making a choice about whether to have an additional screening test after your mammogram.
Talk with your health care provider about which one of these tests is right for you.
Cancer Detection by Screening Test
|If 1,000 Women Are Screened With:||Number of Women Found to Have Cancer|
|2D mammogram alone||5|
|3D mammogram (tomosynthesis)||6*|
|Most Common Additional Screening Tests|
|Mammogram PLUS ultrasound (sonogram)||8|
|Mammogram PLUS contrast-enhanced MRI||15|
|Other Additional Screening Tests|
|Mammogram PLUS Molecular Breast Imaging (MBI)||12|
|Contrast-enhanced mammogram (CEM)||15
Rev. March 2022
- Ultrasound is the most common additional test used after a mammogram. Ultrasound uses sound waves and does not involve radiation or an injection into your vein. Gentle pressure is applied to the breasts and rarely causes discomfort. An Ultrasound screening takes about 15 to 20 minutes.
- Magnetic resonance imaging (MRI) involves an injection of a gadolinium contrast solution into your vein that may feel a little cold while it is injected. You lie on your stomach and your breasts fit into two openings. The contrast-enhanced MRI is done in the tunnel of a large magnet. The magnet makes loud noises while generating images. Contrast-enhanced MRI does not use radiation and takes from 10 to 25 minutes.
- Molecular Breast Imaging (MBI) involves an injection of a radiotracer into your vein. About 5 minutes after the injection, each breast is placed between two detectors, similar to a mammogram but with less pressure. An MBI test takes at least 40 minutes.
- Contrast-enhanced mammogram (CEM) requires an injection of iodine-based contrast into your vein. This is the same contrast used in CT scans. It makes you feel warm all over and you may even feel like you might pee on yourself. After about 2½ minutes, you will have a CEM. A CEM test takes about 10 minutes.
For more information, see Question/Answer: “What are other breast screening tests after my mammogram?“
19. I feel a breast lump, but my most recent screening mammogram was “normal.” What should I do?
You should not ignore a lump or any change in your breasts just because your recent mammogram was “normal.” This is especially important if your breasts are dense. While lumps are often cysts or areas of normal tissue, a lump may be cancer that is hidden within dense breast tissue on a mammogram. If you have a lump, you should talk to your doctor or health provider and have a “diagnostic” breast imaging appointment where often an Ultrasound will be performed.
A “normal,” “negative,” or “benign” screening mammogram report does not necessarily mean there is no cancer.
20. Are a 2D digital mammogram and a 3D mammogram (known as tomosynthesis) the same thing?
No. They are different types of digital mammograms.
To explain the difference, think of a 2D mammogram like a photograph of a book. The words on each page of the book would have their letters jumbled on top of the words from all the other pages, so it would be very difficult to read any particular word. Any given “word” could be a small mass due to cancer.
Now, to understand a 3D mammogram, imagine the cover and pages of the book are see-through. The 3D mammogram captures images at different angles, which allows thin “slice” images to be made by the computer. These images can then be viewed one at a time–similar to turning pages of a book and being able to read the words on each page.
A 2D mammogram finds about 5 cancers for every 1,000 women who have a mammogram. Another 1-2 cancers will be found per 1,000 women when 3D/tomosynthesis is used. With 3D mammograms, you are also less likely to be called back for more testing. However, in women with extremely dense breasts, 3D mammograms have not been shown to find more cancers than 2D mammograms. A cancer “hidden” on a 2D mammogram could still be hidden on a 3D mammogram.
Talk with your health care provider about whether additional testing after your mammogram is right for you. Learn more here.
21. Can I just have screening ultrasound and skip mammography?
No. Ultrasound is not a replacement or substitute for mammography. Some breast cancers are only detected by 2D or 3D/tomosynthesis mammography, even in dense breasts.
22. I am a breast cancer survivor and have dense breasts. Is a mammogram enough screening for me?
Maybe not. Women who have had breast cancer are more likely to get a second breast cancer. Some of these cancers are hard to see on a mammogram. In women who have had breast cancer, MRI can help find cancers not seen on a mammogram.
You should talk to your health care provider about having an annual MRI in addition to a 2D/3D mammogram if:
- You were diagnosed with breast cancer by age 50
- If you have a history of breast cancer and dense breasts
- You are younger than 70-75
If MRI cannot be performed, Ultrasound can be used, but it does not find as many cancers as MRI. If you have a screening MRI, a screening Ultrasound is not needed.
A newer breast imaging tool is contrast-enhanced mammography. This may be an option instead of an MRI. It does show more cancers than Ultrasound, but it is not yet widely available.
If you have had both breasts removed (double mastectomy) and are otherwise in good health, mammograms or other breast imaging tests are not recommended unless there is a lump or other change in the area of surgery or your underarm.
1. Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast cancer screening in women at higher-than-average risk: Recommendations from the ACR. J Am Coll Radiol 2018; 15:408-414
23. At what age should I start getting mammogram screenings?
The goal of mammogram screenings is to find breast cancer EARLY, when it is easier to treat and most survivable.
Though breast cancer is more common as women get older, it is important to begin mammogram screenings by age 40 because:
- Breast cancer is the number one cause of death in women aged 35 to 54 years.
- Beginning by age 40 lowers the chance of dying from breast cancer.
- Beginning by age 40 is especially important for Asian, Hispanic or Black women as they are more often diagnosed with breast cancer at a younger age.
- More than half of women in their 40s have dense breasts (heterogeneously dense or extremely dense). Dense breasts increase the risk of developing breast cancer and can hide cancer on a mammogram. Women with dense breasts should talk to their doctor/health care provider about additional screening after their mammogram.
* Women at “high risk” for breast cancer (for example, those who have a disease-causing genetic mutation such as BRCA1 or BRCA2), should begin getting mammograms even younger – at least by age 30 — and also get an MRI every year.
24. What is a recall or false positive (false alarm) from a mammogram?
About 1 in every 10 women who have a screening mammogram will be called back or “recalled” for extra views or screening tests to look at an area of the breast more closely. THIS IS EXPECTED.
- It is much more common for women to be recalled after their very first mammogram. This is because there is no prior mammogram for comparison to know what is normal for your breasts.
- Among women called back, most (95%) do not have cancer. These are considered “false positives” or “false alarms.”
Usually, extra mammogram pictures or an ultrasound can clear up a question raised on a mammogram.
About 1 in 5 women called back for additional testing will need a needle biopsy. This is a minor in-office procedure to take a very small sample of breast tissue for testing.
25. Does it matter where I have my mammogram?
Yes. In the U.S.A., to legally perform mammography, a facility must be certified and recognized by the U.S. Food and Drug Administration (FDA) which maintains a Mammography Facility Database. Click here for the list of FDA recognized accredited facilities.
An imaging center may receive further accreditation through the American College of Radiology (ACR). The ACR’s accreditation program, which designates Diagnostic Imaging Centers of Excellence®, assesses imaging centers for a number of qualifications (e.g. personnel, policies, equipment, image quality and patient care). Such centers also must have ACR accreditation for stereotactic breast biopsy, ultrasound-guided breast biopsy, and breast MRI. Click here for a list of ACR Diagnostic Imaging Centers of Excellence.
I Have Been Told I Have Dense Breasts, What Should I Do?
26. What are other breast screening tests after my mammogram?
For women with dense breasts, an additional breast screening test after a mammogram may find cancer not seen on the mammogram alone.
Like a mammogram, each type of additional screening has benefits and things to consider. For instance, there is the possibility of being “called back” or “recalled” for more images and sometimes a biopsy. About 1 in every 10 women having a screening mammogram will be called back for extra views or tests to look at an area of the breast more closely. Any additional screening test may also result in a call back. Talk to your health care provider about which one of these tests is right for you.
Out of 1,000 women, about 15 can be diagnosed with breast cancer each year:
- About 5 women will be diagnosed with breast cancer found on their screening mammogram. This means about 10 women will have a cancer missed by their mammogram.
- To identify those 10 women who have breast cancer, an additional breast screening test can be done. Any additional breast screening test may find cancers and also things that look concerning, but that turn out not to be cancer (false alarms).
Cancer Detection by Screening Test
|If 1,000 Women Are Screened With:||Number of Women Found to Have Cancer|
|2D mammogram alone||5|
|3D mammogram (tomosynthesis)||6*|
|Most Common Additional Screening Tests|
|Mammogram PLUS ultrasound (sonogram)||8|
|Mammogram PLUS contrast-enhanced MRI||15|
|Other Additional Screening Tests|
|Mammogram PLUS Molecular Breast Imaging (MBI)||12|
|Contrast-enhanced mammogram (CEM)||15
Rev. March 2022
More to Know About Screening Tests After Your Mammogram
Ultrasound is the most common additional test used after a mammogram. Ultrasound uses sound waves and does not involve radiation or an injection into your vein. Gentle pressure is applied to the breasts and rarely causes discomfort. An Ultrasound test takes about 15 to 20 minutes.
If 1,000 women have an Ultrasound:
- 30 women will have something found on their Ultrasound test and will be recommended to have a needle biopsy (where a small sample of your breast tissue is taken and checked for cancer).
- 2-3 cancers will be found that were not seen on the mammogram.
Magnetic resonance imaging (MRI) involves an injection of a gadolinium contrast solution into your vein that may feel a little cold while it is injected. You lie on your stomach and your breasts fit into two openings. The contrast-enhanced MRI is done in the tunnel of a large magnet. The magnet makes loud noises while images are made. Contrast-enhanced MRI does not use radiation and takes from 10 to 25 minutes.
If 1,000 women have an MRI:
- 50 women will be recommended to have a needle biopsy because of something found on the MRI.
- About 10 additional cancers will be found even after ultrasound and mammography.
Molecular Breast Imaging (MBI) involves an injection of a radiotracer into your vein. About 5 minutes after the injection, each breast is placed between two detectors, similar to a mammogram but with less pressure. The test takes at least 40 minutes.
If 1,000 women have MBI:
- About 30 will be recommended to have a needle biopsy because of something found on MBI.
- About 7 cancers will be found that were not seen on the mammogram.
Contrast-enhanced mammogram (CEM) requires an injection of iodine-based contrast into your vein. This is the same contrast used in CT scans. It makes you feel warm all over and you may even feel like you might pee on yourself. After about 2½ minutes, you will have a CEM. The test takes about 10 minutes.
If 1,000 women have CEM:
- 30-50 women will be recommended to have a needle biopsy because of something found on the CEM.
- About 10 additional cancers will be found that were not seen on their mammograms.
Berg WA, Rafferty EA, Friedewald SM, Hruska CB, Rahbar H. Screening Algorithms in Dense Breasts: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 216:275-294
For more details about breast screening tests, visit our Technology Tab.
27. Does insurance cover my mammogram and any additional tests?
- In the U.S.A, under the Affordable Care Act (Obamacare), insurance carriers are required to cover the full cost of a screening mammogram. A screening mammogram is for women with no symptoms. If the screening is performed by 3D/tomosynthesis mammography, the full cost might not be covered by some insurance companies. It depends on the state in which you live (click here to learn more) and what insurance you have.
- Insurance coverage for additional screening tests after your mammogram, such as Ultrasound or MRI, varies by state and by insurance company. You should check with your insurance carrier(s) to learn if and how additional tests will be covered.
- For women at high risk for breast cancer, most insurers will cover a screening MRI (regardless of density), though a deductible/co-pay may apply, and pre-authorization may be needed.
- A diagnostic mammogram is for women with a sign or symptom of breast cancer, such as a lump or nipple discharge. A diagnostic mammogram is also used if additional mammography views are needed to clear up a question raised on a screening mammogram. A deductible/co-pay will usually apply for a diagnostic mammogram. But again, it depends on where you live and your insurance plan.
In Europe, national breast screening programs for women of average risk are offered in nearly all countries. Variations do exist on the ages and risk factors of women invited to participate in routine screening, how often screening is recommended, and supplemental screening tools used. For specific information by European country, click here.
28. What are insurance billing codes for additional breast screening tests?
- In the U.S.A., medical procedures are billed using both an ICD (International Classification of Disease) code and a CPT (Current Procedural Terminology) code.
- Use those codes to check with your insurance company to learn if a specific test should be covered and what your out-of-pocket costs (copay, deductible, or coinsurance) may be.
- Coverage varies by state and specific insurance plan.
Insurance Billing Codes by Breast Imaging Test
ICD CODE: For women with dense breasts, an appropriate ICD-10 code is 92.2 (which is “inconclusive mammogram” and can be used because of dense breast tissue). Note: other diagnosis codes may also apply based on medical history.
Terms you may hear: one breast = unilateral, both breasts = bilateral
|2D Mammogram (screening)||77067 (both breasts, 2-views of each)||Code also includes computer-aided detection (CAD) when performed.
The Affordable Care Act requires insurers to cover annual screening mammography beginning at age 40, without any out-of-pocket costs.
For younger women at high risk, screening mammography typically requires a prescription from a physician and may be subject to out-of-pocket costs.
|2D Mammogram (diagnostic)||77065 (one breast)|
77066 (both breasts)
|Codes also include computer-aided detection (CAD) when performed.
Diagnostic mammography is typically subject to out-of-pocket costs.
A diagnostic mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual mammogram performed as a diagnostic or a screening examination.
|3D Mammogram/tomosynthesis (screening)||77067 (2D both breasts) + 77063 (3D both breasts )||Most major insurers cover screening tomosynthesis; additionally, many states now require coverage. Out-of-pocket costs are possible.|
|3D Mammogram/tomosynthesis (diagnostic)||77065 (2D one breast) + 77061 (3D one breast)|
77066 (2D both breasts) + 77062 (3D both breasts)
G0279 – 3D (one or both breasts) if Medicare is primary insurance
|Out-of-pocket costs usual.
A diagnostic 3D mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual 3D mammogram performed as a diagnostic or a screening examination.
|Contrast-enhanced Mammogram (CEM)||Currently no CPT code|| Most CEM is done as part of research studies at this time.
In centers offering clinical CEM, billing is often under CPT code 77065 (one breast) or 77066 (both breasts). Out-of-pocket costs usual.
Some centers will also bill for the contrast and the contrast injection.
|Ultrasound||76641 (per breast)||“Complete” breast ultrasound is used for screening and will be billed for each breast, usually at half the rate for the second breast. Out-of-pocket costs usual in most states.
A “limited” breast ultrasound, 76642, is used to evaluate abnormalities or particular areas of concern.
|Molecular Breast Imaging, MBI||78800||Out-of-pocket costs usual.|
|Magnetic Resonance Imaging, MRI (with contrast)||77048 (one breast)|
77049 (both breasts)
|May require pre-authorization from your health provider. Out-of-pocket costs usual in most states.|
|Abbreviated MRI (with contrast)||Currently no CPT code unique to abbreviated MRI.||Many centers will bill directly to the patient (range $200-$600). The American College of Radiology endorses use of the modifier, “-52” (limited) exam, in combination with full protocol MRI CPT code 77049 (click HERE for more details, page 12).
Updated Nov 3, 2021. DenseBreast-info.org endeavors to provide up-to-date insurance codes; however, codes can change. These codes may not be the most recent version. No representations or warranties of any kind are made, express or implied, about the completeness, accuracy or reliability of this information provided. A patient should always check with their specific insurance provider.
29. If I have a 3D/tomosynthesis mammogram, do I also need a screening ultrasound or MRI?
Yes, you may still need more screening if you have dense breasts and/or are at high risk. Ultrasound or MRI might find cancers even after “normal” 3D mammograms. This has been shown in several large studies. It is still important to have your mammogram, as mammograms do find some cancers that Ultrasound or MRI may not find. The combination of tests finds the most cancers. If you are recommended to have a screening MRI because of risk factors, you will still need to have an MRI even if you have a 3D/tomosynthesis mammogram. But if you have an MRI, there is no need to also have a screening Ultrasound.
1. Tagliafico AS, Mariscotti G, Valdora F, et al. A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2). Eur J Cancer 2018; 104:39-46
2. Destounis S, Arieno A, Morgan R. Comparison of cancers detected by screening ultrasound and digital breast tomosynthesis. Abstract 3162. In: American Roentgen Ray Society (ARRS). New Orleans, LA, 2017
3. Tagliafico AS, Calabrese M, Mariscotti G, et al. Adjunct screening with tomosynthesis or ultrasound in mammography-negative dense breasts (ASTOUND): Interim report of a prospective comparative trial. J Clin Oncol 2016
4. Dibble EH, Singer TM, Jimoh N, Baird GL, Lourenco AP. Dense breast ultrasound screening after digital mammography versus after digital breast tomosynthesis. AJR Am J Roentgenol 2019; 213:1397-1402
5. Comstock CE, Gatsonis C, Newstead GM, et al. Comparison of abbreviated breast MRI vs digital breast tomosynthesis for breast cancer detection among women with dense breasts undergoing screening. Jama 2020; 323:746-756
30. If I have dense breasts, should my routine annual mammogram be scheduled as a “screening” or a “diagnostic” mammogram?
Your routine annual mammogram should be scheduled as a “screening” mammogram. Screening mammograms are for women with no signs or symptoms of breast cancer, whether you have dense breasts or not. In the U.S.A, screening mammograms are fully covered by insurance under the Affordable Care Act for women over the age of 40, and may be covered for younger women, if recommended by her physician and depending on the insurance policy.
“Diagnostic” mammograms are used when there are signs and symptoms of breast cancer such as a lump, bloody or spontaneous clear nipple discharge, and/or skin or nipple retraction. Diagnostic mammography is typically covered by insurance, but is subject to deductible and copay.
31. If I am recommended to have additional screening with Ultrasound or MRI, will I need to have that every year?
You should discuss this with your health care provider or breast imager because, as you get older, your personal risk factors and the benefits and types of additional screening recommended may change. It is therefore important to review your risk factors every year or two with your health care provider to determine what screening plan is best for you.
32. Is MBI or BSGI recommended for screening women with dense breasts?
Molecular Breast Imaging (MBI) and Breast Specific Gamma Imaging (BSGI) are specialized nuclear medicine procedures that can detect cancers hidden within dense breast tissue on a mammogram; these imaging procedures are not generally recommended for screening.
These tests require an injection of a small amount of radioactive material, which circulates throughout the body. Breast cancers take up the radiotracer more than normal cells do. This allows the cancer to be seen on special cameras. An advantage of these tests is that they are not affected by breast density. A disadvantage is that the radiation from these tests is to the whole body, unlike mammography, where only the breasts receive radiation (in a very small amount), and unlike ultrasound or MRI, where there is no radiation at all.
There are ongoing studies to see if the radiation dose from these tests can be lowered so that they can be widely used for screening. However, for now, MBI and BSGI are most often used as diagnostic tools.
A diagnostic tool is one which helps diagnose cancer once a symptom appears (for example, a lump that can be felt), or when there is a vague area of possible concern found after additional mammogram views and ultrasound. MBI or BSGI can also be helpful for some women who need, but cannot have an MRI. These tests are not used in women who are pregnant.
1. Rhodes DJ, Hruska CB, Conners AL, et al. JOURNAL CLUB: Molecular breast imaging at reduced radiation dose for supplemental screening in mammographically dense breasts. AJR Am J Roentgenol 2015; 204:241-251
33. Should thermography be used for screening dense breasts?
No. Thermography is a technique that uses infrared technology to detect both heat and blood flow patterns very near the skin’s surface, and some large cancers can be seen this way. However, thermography has a high “false negative” rate (when a test result indicates “no cancer” even though cancer is actually present), especially for small breast cancers. It can also have “false positives” (when a test result indicates cancer may be present when it is not).
According to the United States Food and Drug Administration, “There is no valid scientific data to demonstrate that thermography devices, when used on their own or with another diagnostic test, are an effective screening tool for any medical condition including the early detection of breast cancer or other diseases and health conditions.” Thermography is not an accurate test and is not recommended for screening.
1. US Food and Drug Administration. FDA warns thermography should not be used in place of mammography to detect, diagnose, or screen for breast cancer: FDA Safety Communication. https://www.fda.gov/medical-devices/safety-communications/fda-warns-thermography-should-not-be-used-place-mammography-detect-diagnose-or-screen-breast-cancer Published February 25, 2019. Accessed May 18, 2020.
What Are Factors That May Affect Breast Density?
34. Can I change my breast density with diet or exercise? Is my breast density related to the fat in my diet?
No. Fat content in what you eat and exercise do not directly change breast density. But if you lose or gain a lot of weight, your breasts can look more or less dense on your mammogram – though the amount of dense tissue will stay the same. This is because if you gain weight, there will be more fatty tissue (non-dense) in your breasts. If you lose weight, you will lose fatty tissue from your breasts. So, although the foods you eat and exercising do not change your breast density, your overall body fat can affect your breast density.
For more information, see Q+A, “Will my breasts always be dense?”
35. Does taking estrogen affect breast density?
Yes. An increase in breast density is often seen in women taking combined estrogen and progesterone hormone replacement therapy (HRT), and sometimes in women using oral low-dose estrogen, vaginal estrogen, or transdermal estrogen treatment. The increase in density is often apparent within months of beginning hormone therapy. Risk of breast cancer also increases in women taking combined hormone therapy.
36. Can I decrease my breast density by taking tamoxifen?
Maybe. In some women, tamoxifen does decrease breast density. Tamoxifen works by blocking estrogen in the breast. Tamoxifen is sometimes prescribed to decrease the chance that cancer will return in women who have had estrogen receptor positive (ER-positive) breast cancer. It may also be prescribed to reduce the risk of developing breast cancer in women who have had prior atypical biopsy or those at higher risk for breast cancer for other reasons.
Early studies suggest that only those women who experience a decrease in their breast density while taking tamoxifen will experience a decreased risk of getting an ER-positive cancer. The extent of change in breast density due to tamoxifen is small.
It is important to be aware that tamoxifen therapy has risks. Tamoxifen increases a woman’s risk of blood clots and of cancer of the lining of the uterus.
37. Will taking Arimidex or other aromatase inhibitors affect my breast density?
Maybe. Aromatase inhibitors (AIs) block your body’s own production of estrogen. AIs are prescribed for postmenopausal women who have had estrogen receptor positive (ER-positive) breast cancer. One study of breast cancer survivors taking AIs showed that those survivors who experienced a decrease in their breast density had a lower risk of recurrence than women who did not experience a decrease in breast density.
1. Kim J, Han W, Moon HG, et al. Breast density change as a predictive surrogate for response to adjuvant endocrine therapy in hormone receptor positive breast cancer. Breast Cancer Res 2012; 14:R102
2. Kim J, Han W, Moon HG, et al. Erratum to Breast density change as a predictive surrogate for response to adjuvant endocrine therapy in hormone receptor positive breast cancer. Breast Cancer Res 2012; 14:403
38. If I am a breast cancer survivor, is there a correlation between dense breasts and the likelihood of cancer in my opposite breast?
Yes. If you have a history of breast cancer and have dense breasts, there is a greater risk of developing cancer in the opposite breast (known as contralateral breast cancer). The good news is that this risk can be reduced with treatment. Tamoxifen (premenopause) or aromatase inhibitors (postmenopause) are medications given to women with “ER-positive” breast cancer to reduce risk of developing future breast cancer. That reduced risk is only seen if your breast density is reduced by at least 10% (when measured by special software). Knowing whether or not your breast density was affected by the medication may help you decide whether or not to continue the medication.
1. Raghavendra A, Sinha AK, Le-Petross HT, et al. Mammographic breast density is associated with the development of contralateral breast cancer. Cancer 2017; 123:1935-1940
2. Sandberg ME, Li J, Hall P, et al. Change of mammographic density predicts the risk of contralateral breast cancer–a case-control study. Breast Cancer Res 2013; 15:R57
3. Engmann NJ, Scott CG, Jensen MR, et al. Longitudinal changes in volumetric breast density with Tamoxifen and aromatase inhibitors. Cancer Epidemiol Biomarkers Prev 2017; 26:930-937
4. Cuzick J, Warwick J, Pinney E, et al. Tamoxifen-induced reduction in mammographic density and breast cancer risk reduction: a nested case-control study. J Natl Cancer Inst 2011; 103:744-752
39. Do lumpy breasts or fibrocystic breasts mean I have dense breasts?
No. Having “lumpy” or fibrocystic breasts does not always mean you have dense breasts. The way to tell if you have dense breasts is with a mammogram. Your health care provider cannot tell if your breasts are dense by a physical exam.
Breasts (of any density category) can feel lumpy as the ligaments which support the breast tissue can surround fat lobules and make them feel like soft grapes. Remember, fibrocystic change is a benign (non-cancerous) condition that is more common when women are young. Fibrocystic changes usually decrease after menopause. Fibrocystic breasts can appear dense due to cysts and/or areas of fibrosis (which resemble scar tissue).
40. Is breast density an issue that affects men?
No. Normal male breasts are mostly fatty. However, it is important to remember that men do get breast cancer. Men can develop breast tissue (known as gynecomastia) as they age or as a side effect of some medicines; however, gynecomastia is nothing to worry about. Sometimes, a mammogram is performed in men to evaluate a lump that may be due to gynecomastia or breast cancer.
41. Can breast density be inherited?
Breast density is at least partially inherited. If your mother or sister has dense breast tissue, it’s more likely you will too.
42. Does the increase in breast density while I am breastfeeding affect the accuracy of my mammogram?
Yes. Changes in the breast during breastfeeding do reduce the accuracy of mammography, but mammograms are still recommended. Depending on your individual risk factors, Ultrasound or MRI may sometimes be added to mammography for additional screening. Breastfeeding also affects the appearance of the breasts on Ultrasound and MRI.
43. Do Black women have denser breasts?
There have been conflicting studies on whether Black women have denser breasts. One study indicated they do not, while a more recent study indicated they do have denser breasts.
1. del Carmen MG, Halpern EF, Kopans DB, et al. Mammographic breast density and race. AJR Am J Roentgenol 2007; 188:1147-1150
2. McCarthy AM, Keller BM, Pantalone LM, et al. Racial differences in quantitative measures of area and volumetric breast density. J Natl Cancer Inst 2016; 108
44. Do Asian women have denser breasts?
Generally, Asian women do have denser breasts than women of other races.
45. What if I have dense breasts and a disease-causing BRCA gene mutation?
BRCA gene mutations and dense breasts are both risk factors for breast cancer. However, BRCA1 or BRCA2 mutations are associated with a much higher risk for developing breast cancer than is the risk from having dense breasts.
Because BRCA gene carriers are more likely to develop breast cancer at a younger age, they typically have breast MRI as part of their routine screening. Screening should also start earlier, with MRI beginning at age 25 and also mammography starting at age 30. The addition of MRI screening for women with BRCA mutations is recommended whether or not they have dense breasts.