Dense breast tissue? Issues and comparative techniques

I’ve recently become involved - thanks to another cancer survivor friend back in New York state - with the Are You Dense campaign to inform women of the risks involved with relying too heavily on mammography alone if they have dense breast tissue as defined by the BIRADS Scale - a way that radiologists can classify the images seen on a mammogram.

Here’s is a basic bit on the physic and limitations of mammograms that you should be aware of, particularly if you pre or peri menopausal:

Basic Physics of Mammography:

X-ray images depend on differences in x-ray stopping power (attenuation) to separate tissues. In general, a clear separation between normal functioning tissue, and abnormal cancerous tissues is not possible since their attenuation if very similar. However both functional tissue and cancer can be separated from fatty storage tissues which normally surround active breast tissue, even in lean persons. This is due to a substantially lower attenuation caused by fat.

In older women, the functional glandular tissue diminishes, leaving only thin supporting tissues clearly outlined by fatty tissues. Mammography in these “mature” breasts is very effective, since even small cancers are well outlined by fat. In addition, many cancers develop calcium deposits which strongly stop X-rays and are easily seen on mammograms.

Basic Limitations of Mammography:

Since mammography cannot separate normal gland tissue from tumors, it is much more effective when gland tissue diminishes with age. Many women retain glandular tissue as they “mature”, and it camouflages tumors until they are large. As you might expect, the young women’s breast normally contains more active tissue, which again interferes with detection of small cancers.

Breast Composition Determination:

The ACR-BIRAD system recognizes this limitation by reporting the background composition of the breast in categories:

1.) Almost Entirely Fatty: Mammography very effective, sensitive to even small tumors.

2.) Scattered Fibroglandular tissue: Minor decrease in sensitivity.

3.) Heterogeneously Dense tissue present: moderate decrease in sensitivity.

4.) Extremely dense tissue present: marked decrease in sensitivity.

Mammography does retain some value even in dense breasts, by detecting calcium deposits (which are so dense, surrounding tissue does not interfere), but is not reliable in detecting small non-calcified cancers. In general, women with “dense” breasts remain so from year to year, and it is possible to let a women know when she cannot depend on mammography. In dense breasts, more emphasis on self-examination may be appropriate, particularly if there is a family history of breast cancer.

My breast cancer -  as determined by mammogram alone here in Reno - was supposedly ‘early stage’. Unfortunately, that wasn’t really the case. Had I allowed treatment, using this inaccurate staging, my chances of survival would have been very slim at best. Even pursuing a biopsy here would have set me on a course of disasterous results. Canceling my surgery without so much as discussion of a biopsy - that had been hastily scheduled by a local surgeon - I went OUT OF THE AREA to get a second opinion. By out of area, I don’t mean to the next town. That’s not out of area. I went to the University of Texas, MD Anderson Cancer Center in Houston, Texas which is a multi-disciplinary cancer center. There are many multi-disciplinary, comprehensive cancer centers located around the country and you probably have one near you.

I chose MD Anderson because, A- they were consistently ranked as either the number 1 or 2 leading cancer center in the entire country, B- what they told me was so educational/informational/rational and made such good sense in a way I could understand, that there was no question of going elsewhere. They made a strong, comprehensive case and backed it up, unlike the docs in Reno who seemed to be playing it by ear.

Bottom line: My cancer WAS NOT EARLY STAGE. It was late stage and large, requiring an entirely different treatment protocol. This was because I had extremely dense, fibrocystic breast tissue which had obscured the tumor. I knew about this from an ultrasound years before, but nobody ever explained how this mattered to me - how it would decrease my chances of getting an accurate mammogram, and find a cancer early when it was most treatable.

There are different types of breast imaging modalities now available. They each have their pluses and minuses. But when used appropriately - in concert with each other - they provide powerful tools to accurately depict and diagnose breast cancer at its earliest stage.

You can click on this image for more information

Here is a great comparative discussion of the different breast imaging modalities. The include breast ultrasound, Molecular Breast Imaging, Breast MRI, PEM and others.

To this end, however, it’s imperative that more women understand their own breast tissue density and what that implies regarding the ability of diagnostic radiologists in their area to get the best, most precise picture of their breast tissue and any abnormalities. Connecticutt has actually passed a law that women must be informed of this. Every state should have this mandate on their books, despite what the TeaParty and Libertarians think about mandates. In this case, at least, they save lives.

One caveat is important to remember. Ultrasound - which is an extremely accurate and useful way of viewing breast tissue - is highly dependant on the skill, experience and overall expertise of the technician/operator. At present, there is a shortage across the United States of ultrasound techs that can truly utilize this modality to its best. This is another reason to get the hell out of your local area and go to a cancer center - somewhere that does nothing but breast imaging - by the thousands.

These centers attract the best of the best in technical expertise - like MD Anderson and other comprehensive cancer centers. There is simply no substitute for this, since that initial diagnosis and staging is so critical to the ultimate outcome of breast cancer treatment and whether the cancer recurs.

At MD Anderson, the doctor that did all the ultrasounds on my breasts has been a leader in the field for many years. He was able to actually assess the involvement of the lymph nodes prior to any surgery or biopsy. Later, when a suspicious lesion was found, he was able to guide a Fine Needle Aspiration biopsy - with the Pathologist and her microscope right in the ultrasound room to read it immediately - by ultrasound. It was determined right then and there that it was a benign lesion. This put my anxieties to rest immediately - no waiting around for a report a week later.

Every woman should have some clue as to what the different ‘architectures’, tissues, masses and such look like and what the meanings are - this keeps you from being unnecessarily frightened by a report. Remember, knowledge is power. It can also help you sleep nights.

Read through the information on this Creighton University mammography website. Bookmark it. Refer to it before you get your mammogram, and even print it out and take it with you so that you can rationally discuss any initital findings right there with the radiologist.

For more information on breast tissue density, click on the following:

So, please … get the facts. Read all you can. Don’t become a victim of the local ‘we’ve always done it this way’ mentality. You get one first chance to beat breast cancer - any cancer - and you MUST get it right the first time.

You may not live to be a ‘wish I had only …’

-maven