E.U.

Dense breasts are “normal.” In fact, 40% of women over age 40 have dense breasts. But dense breast tissue can hide cancer on a mammogram and can reduce the effectiveness of mammography screening. So a “normal,” “negative,” or “benign” mammogram result does not reliably exclude cancer in women with dense breasts. This is why, sometimes, a woman with dense breasts may have cancer detected soon after a “normal,” “negative,” or “benign” mammogram. This is known as an “interval cancer.” To find cancer in a woman with dense breasts, additional screening should be considered. See flow chart: Who Needs More Screening? (or, in Europe, European Screening Decision Support Tool).

It is important for any woman not to ignore a lump just because the recent mammogram was normal, and this is especially important if the breasts are dense. While cysts, other benign masses, and areas of normal tissue can present as lumps, malignant masses, especially those lacking calcifications, are frequently masked by dense breast tissue and a “normal,” “negative,” or “benign” mammogram does not mean that there is no cancer present. Tomosynthesis can help show some cancers not found with 2D-mammography, but ultrasound is the test of choice to evaluate palpable lumps and allows targeted assessment and correlation of the area being felt with findings on ultrasound. If there is a mass suspicious for cancer, the radiologist/technologist may also include ultrasound of the tissue in the axilla (under the arm) because the first place cancer will spread is to lymph nodes in the axilla. Cancers presenting because of symptoms prior to the next annual mammogram are called “interval cancers” and interval cancers are increasingly common with increasing breast density.

Based on randomized trials (invitation to screening) mammography, there is at least a 15% decrease in deaths due to breast cancer in women screened in their 40s and a 22% reduction in deaths among women screened from ages 50 to 74 [1]. In observational studies of women actually having mammographic screening, reduction in deaths due to breast cancer is closer to 40% [2, 3]. Based on these results, the American College of Radiology (ACR) recommends annual screening beginning at age 40 for women at average risk for breast cancer [4]. The European Society of Breast Imaging (EUSOBI) recommends biennial screening mammography for average-risk women aged 50–69 years; extension up to 73 or 75 years biennially and from 40–45 to 49 years, annually [5]. Breast cancer incidence peaks earlier, in the 40s, for African American, Asian, and Hispanic women [6], than for Caucasian women when the peak is in the early 50s. As such, it is especially important for African American, Asian, and Hispanic women to start screening by age 40. The age to stop screening should be based on a woman’s overall health status. Women with a life expectancy less than 5-7 years are unlikely to realize a benefit from screening mammography.

Women at high risk for breast cancer, because of known or suspected disease-causing variants (mutations) in BRCA or other genes such as P53, should begin screening earlier; American Cancer Society recommendations, as well as those of the European Society of Mastology (EUSOMA), include annual MRI [7, 8]: BRCA-1 carriers should begin by age 25, and BRCA-2 carriers by age 30. Women with a history of radiation therapy to the chest (e.g., for Hodgkin’s disease) before age 30 should begin screening with mammography and MRI at age 25, or 8 years after treatment, whichever is later. Emerging evidence suggests that for BRCA-1 carriers who have annual MRI, the benefit of mammography is relatively small before age 40 [9]. Once a woman has had breast cancer, she should have at least annual mammography; if she also has dense breasts and/or was diagnosed with breast cancer by the age of 50, the ACR recommends she consider annual MRI in addition to mammography [10].

For other women with a family history of breast cancer, it is important to consider many factors, including the age at diagnosis of family members. Several risk models have been developed. While all models can over- or underestimate risk in a given individual, the Tyrer-Cuzick model is the most consistently accurate and, as of September 2017, includes breast density as a risk factor. For women estimated to have a lifetime risk of breast cancer of 20% or more, annual MRI screening has been recommended in addition to mammography [7, 10].

Women should begin screening at age 40. Though breast cancer is more common as women get older, it is still important to begin screening at 40 because:

• We screen for breast cancer to find it EARLY, when it is easier to treat and most survivable.
• Breast cancer is the number one cause of death in women aged 35 to 54 years.
• Deaths from breast cancer are reduced the most when screening starts at age 40. The most years of life are saved when screening starts at age 40.
• More than half of women in their 40s have dense breasts (heterogeneously dense or extremely dense). Dense breast tissue increases the risk for developing breast cancer and the consideration of additional screening after a mammogram.
• Women at “high risk” for breast cancer, most often because they have a disease-causing mutation (such as BRCA1 or BRCA2), should begin screening even younger – at least by age 30 and with the inclusion of an MRI.

WHAT ABOUT FALSE ALARMS (KNOWN AS “FALSE POSITIVES”)?

• About 10% of women having a screening mammogram will be called back (recalled) for extra testing or views. THIS IS NORMAL. Among women called back, 95% do not have cancer. If a needle biopsy is necessary, even that is a simple test not much different from a dental filling.
• The newer technique of 3D-mammography (also known as tomosynthesis), is better able to show cancer AND results in fewer callbacks for extra testing.

WHAT ABOUT SCREENING IN DENSE BREASTS?

• Younger women are more likely to have dense breast tissue that can hide cancer on mammography.
• In women who have breasts categorized as “dense” (heterogeneously dense or extremely dense), adding screening ultrasound after a mammogram can help find more breast cancers. However, ultrasound also finds areas/masses that are not cancer and increases the chance of needing a needle biopsy to determine if such areas/masses detected are cancerous or not.

IS IT COVERED?

• Under the Affordable Care Act, insurance carriers are required to cover the full cost of screening mammography. If the screening is performed by 3D mammography (tomosynthesis), the full cost might not be covered by some insurance companies in some states.
• Insurance coverage for additional screening tests, such as ultrasound or MRI, varies by state and by insurance company. Women should check with their insurance carriers to determine how additional tests will be covered. In women at high risk for breast cancer, most insurers will cover screening MRI (regardless of density) though a deductible/co-pay will typically apply, and pre-authorization may be needed.
• Diagnostic mammography is performed to evaluate abnormalities found on screening or when a woman has signs or symptoms of breast cancer. A deductible/co-pay will usually apply for diagnostic mammography.