Mammograms have long been the gold standard for breast cancer detection, but they're not perfect. They can be less effective in women with dense breasts, which contain more glandular and connective tissue than fat.
Many states now require women to be notified when dense tissue is seen on a mammogram. Some states also require supplemental screening, like ultrasound, even if the mammogram found no cancer.
In this segment, Dr. Lusi Tumyan discusses breast density as a risk for breast cancer and the latest screening indications for women with dense breasts.
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Dense Breasts and Screening Indications
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Learn more about Lusi Tumyan, MD
Lusi Tumyan, MD
Lusi Tumyan, M.D., is an assistant clinical professor in the Department of Diagnostic Radiology. Dr. Tumyan received her undergraduate degree in biochemistry from Occidental College in Los Angeles where she was elected to Phi Beta Kappa, and went on to obtain her medical doctorate from the David Geffen School of Medicine at UCLA. She completed a medicine internship at Huntington Memorial Hospital in Pasadena, CA, and went on to complete her training as a general radiology resident at the LAC+USC Medical Center in Los Angeles, CA. Dr. Tumyan also completed a fellowship in breast imaging at the Iris Cantor University of California, Los Angeles Women’s Health Center.Learn more about Lusi Tumyan, MD
Transcription:
Dense Breasts and Screening Indications
Melanie Cole (Host): Mammograms have long been the gold standard for breast cancer detection, but they are not perfect. They can be less effective in women with dense breasts which contain more glandular and connective tissue than fat. Many states now require women to be notified when dense breast tissue is seen on a mammogram. Some states also require supplemental screening like ultrasound even if the mammogram found no cancer. My guest today is Dr. Lusi Tumyan. She is a radiologist in the department of diagnostic radiology and the Chief of Breast Imaging at City of Hope. Welcome to the show Dr. Tumyan. So, what are dense breasts?
Dr. Lusi Tumyan, MD (Guest): Our breasts and just like everything else about us is different from one person to another. So, our breast parenchyma, what is composed of our breasts, whether it is connective tissue, whether it is fibro glandular tissue or whether it is fat; we all have different compositions. Some people have a lot more fat than they have other connective tissue or fibro glandular tissue. Other people will have a lot more fibro glandular tissue and connective tissue and less fat. On a mammogram, fibro glandular tissue and connective tissue shows up as white. Unfortunately, cancer also shows up as that white. So, if patient has a lot more fibro glandular tissue than fat, sometimes the fibro glandular tissue will mask the cancer which means that the radiologist is unable to pick up the cancer because there is a lot of tissue overlap and we just cannot see it on mammogram. In those patients, the mammogram is less sensitive than in patients that majority of their breasts composed of fatty tissue. About 50% of our population, is patients that do have dense breast parenchyma and in those cases, mammogram becomes less sensitive in detection of breast cancer.
Melanie: So, how does a woman know if she has dense breasts?
Dr. Tumyan: In the state of California, the woman will get a letter when they have a mammogram which will tell them the results of the mammogram. In that letter, when the patient does have dense breasts; we are required to notify our patients. In that letter will state that you have dense breasts parenchyma and it is something to be discussed with your referring clinician. You may look into supplemental screening modalities and examination.
Melanie: So, if someone receives that letter, and it can be worrisome; you have already stated how many people have it so it is not abnormal. Does it increase our risk for breast cancer?
Dr. Tumyan: It is extremely worrisome and it is extremely anxiety provoking, especially since this is a new law that went into effect a couple of years ago. So, previously, women did not get that notification. Once the law was enacted, women were getting new notifications and once you see that; you become very anxious about it. There have been several studies that have shown that patients with dense breasts do have slightly increased risk of breast cancer compared to populations that do not have dense breasts. So, yes, the risk of breast cancer is slightly, not a lot, likely higher in dense breasted women.
Melanie: So, do women still need to get their mammogram or should they discuss with their doctor some of these adjuvant imaging techniques?
Dr. Tumyan: Women should always get mammograms because mammogram has been shown to decrease mortality and mammogram is the gold standard for detection of breast cancer. Also, mammogram is the best modality to find breast calcifications and breast calcifications, some of breast calcifications are associated with early breast cancer. So, mammograms should always be part of their regimen. However, in patients that do have dense breast parenchyma, it is worth talking to your clinician and determining your risk factors for breast carcinoma. For patients that do have dense breast parenchyma, there are supplemental imaging that could be performed. These would include either an ultrasound of the breasts or MRI. If a woman is determined to be average risk for breast cancer based on their overall risk factors; ultrasound is a great supplemental examination in addition to mammogram to screen for breast cancer. For patients that have high risk of breast cancer based on their overall profile; MRI is a great supplemental technique. It is very sensitive and it is very good to catch early breast cancer in addition working as a compliment with mammogram.
Melanie: So, Dr. Tumyan, if a woman is doing her self-exams every month; does dense breast tissue affect what we feel?
Dr. Tumyan: Yes. Having dense breast tissue sometimes will mask smaller lesions, so small cancers that develop because there is so much fibro glandular tissue and so much connective tissue; detecting very tiny cancers is harder when they are doing breast self-exams. For patients that have fatty tissue, you can detect these easier.
Melanie: So, does insurance recognize those supplemental tests, like MRI or ultrasound if a woman has received that letter, does she then check with her insurance company? Are they recognizing this?
Dr. Tumyan: Some states, when asked for, as for requiring the insurance companies to pay for the supplemental examinations. California has not gone that far. California law says that we have to let the patient know, however, it is not requiring the insurance companies to pay for supplemental examinations. Majority of our insurance companies will pay for ultrasounds. We haven’t seen too much difficulty with getting whole breast ultrasounds, however, insurance companies it is becoming extremely difficult to get breast MRIs. Breast MRIs are really reserved for patients that have increased risk of breast cancer and just having dense breasts, majority of our patients do not qualify for breast MRI and the insurance companies will not pay for that.
Melanie: Is there a difference in the view if someone goes for 3-D or tomosynthesis? Is there a difference with dense breasts?
Dr. Tumyan: Three-D or tomosynthesis is better for dense breast parenchyma because we are able to actually see the breast in three dimensions and we can scroll back and forth within the breast parenchyma and detect more lesions.
Melanie: And what about breast feeding? Does this affect that at all?
Dr. Tumyan: Breast feeding definitely affects the breast density. In fact, when patients do breast feed, we advise them to get their mammograms after they are done breastfeeding. While they are breastfeeding, our glands, fibro glandular tissue, everything increases, so our density – the breast density becomes extremely dense. It is extremely difficult to find cancers in those patients. So, yes, breastfeeding does affect it.
Melanie: So, summarize it for us Dr. Tumyan. What would you like women to know about the laws about getting the letter that informs them that they have dense breast tissue and there may be slightly increased risk of cancer but still getting those mammograms on a regular basis? What would you like to tell them?
Dr. Tumyan: I want to let them know that for patients in California, when they do get the dense breasts letter; it is just something to consider and talk to your doctor and individualize your personal breast cancer screening with your physician. It should be a conversation to this and it should be a balanced discussion with your clinician to determine your overall risk factors for breast carcinoma. Once you determine your overall risk factors; then determine what additional supplemental, if any, examinations would be appropriate for you. If you are average risk; consider ultrasound, always consider 3-D tomography because that is really good for dense breasts. If you are high risk; then consider adding MRI to your screening mammogram.
Melanie: Thank you So much Dr. Tumyan for being with us today. You are listening to City of Hope Radio and for more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Dense Breasts and Screening Indications
Melanie Cole (Host): Mammograms have long been the gold standard for breast cancer detection, but they are not perfect. They can be less effective in women with dense breasts which contain more glandular and connective tissue than fat. Many states now require women to be notified when dense breast tissue is seen on a mammogram. Some states also require supplemental screening like ultrasound even if the mammogram found no cancer. My guest today is Dr. Lusi Tumyan. She is a radiologist in the department of diagnostic radiology and the Chief of Breast Imaging at City of Hope. Welcome to the show Dr. Tumyan. So, what are dense breasts?
Dr. Lusi Tumyan, MD (Guest): Our breasts and just like everything else about us is different from one person to another. So, our breast parenchyma, what is composed of our breasts, whether it is connective tissue, whether it is fibro glandular tissue or whether it is fat; we all have different compositions. Some people have a lot more fat than they have other connective tissue or fibro glandular tissue. Other people will have a lot more fibro glandular tissue and connective tissue and less fat. On a mammogram, fibro glandular tissue and connective tissue shows up as white. Unfortunately, cancer also shows up as that white. So, if patient has a lot more fibro glandular tissue than fat, sometimes the fibro glandular tissue will mask the cancer which means that the radiologist is unable to pick up the cancer because there is a lot of tissue overlap and we just cannot see it on mammogram. In those patients, the mammogram is less sensitive than in patients that majority of their breasts composed of fatty tissue. About 50% of our population, is patients that do have dense breast parenchyma and in those cases, mammogram becomes less sensitive in detection of breast cancer.
Melanie: So, how does a woman know if she has dense breasts?
Dr. Tumyan: In the state of California, the woman will get a letter when they have a mammogram which will tell them the results of the mammogram. In that letter, when the patient does have dense breasts; we are required to notify our patients. In that letter will state that you have dense breasts parenchyma and it is something to be discussed with your referring clinician. You may look into supplemental screening modalities and examination.
Melanie: So, if someone receives that letter, and it can be worrisome; you have already stated how many people have it so it is not abnormal. Does it increase our risk for breast cancer?
Dr. Tumyan: It is extremely worrisome and it is extremely anxiety provoking, especially since this is a new law that went into effect a couple of years ago. So, previously, women did not get that notification. Once the law was enacted, women were getting new notifications and once you see that; you become very anxious about it. There have been several studies that have shown that patients with dense breasts do have slightly increased risk of breast cancer compared to populations that do not have dense breasts. So, yes, the risk of breast cancer is slightly, not a lot, likely higher in dense breasted women.
Melanie: So, do women still need to get their mammogram or should they discuss with their doctor some of these adjuvant imaging techniques?
Dr. Tumyan: Women should always get mammograms because mammogram has been shown to decrease mortality and mammogram is the gold standard for detection of breast cancer. Also, mammogram is the best modality to find breast calcifications and breast calcifications, some of breast calcifications are associated with early breast cancer. So, mammograms should always be part of their regimen. However, in patients that do have dense breast parenchyma, it is worth talking to your clinician and determining your risk factors for breast carcinoma. For patients that do have dense breast parenchyma, there are supplemental imaging that could be performed. These would include either an ultrasound of the breasts or MRI. If a woman is determined to be average risk for breast cancer based on their overall risk factors; ultrasound is a great supplemental examination in addition to mammogram to screen for breast cancer. For patients that have high risk of breast cancer based on their overall profile; MRI is a great supplemental technique. It is very sensitive and it is very good to catch early breast cancer in addition working as a compliment with mammogram.
Melanie: So, Dr. Tumyan, if a woman is doing her self-exams every month; does dense breast tissue affect what we feel?
Dr. Tumyan: Yes. Having dense breast tissue sometimes will mask smaller lesions, so small cancers that develop because there is so much fibro glandular tissue and so much connective tissue; detecting very tiny cancers is harder when they are doing breast self-exams. For patients that have fatty tissue, you can detect these easier.
Melanie: So, does insurance recognize those supplemental tests, like MRI or ultrasound if a woman has received that letter, does she then check with her insurance company? Are they recognizing this?
Dr. Tumyan: Some states, when asked for, as for requiring the insurance companies to pay for the supplemental examinations. California has not gone that far. California law says that we have to let the patient know, however, it is not requiring the insurance companies to pay for supplemental examinations. Majority of our insurance companies will pay for ultrasounds. We haven’t seen too much difficulty with getting whole breast ultrasounds, however, insurance companies it is becoming extremely difficult to get breast MRIs. Breast MRIs are really reserved for patients that have increased risk of breast cancer and just having dense breasts, majority of our patients do not qualify for breast MRI and the insurance companies will not pay for that.
Melanie: Is there a difference in the view if someone goes for 3-D or tomosynthesis? Is there a difference with dense breasts?
Dr. Tumyan: Three-D or tomosynthesis is better for dense breast parenchyma because we are able to actually see the breast in three dimensions and we can scroll back and forth within the breast parenchyma and detect more lesions.
Melanie: And what about breast feeding? Does this affect that at all?
Dr. Tumyan: Breast feeding definitely affects the breast density. In fact, when patients do breast feed, we advise them to get their mammograms after they are done breastfeeding. While they are breastfeeding, our glands, fibro glandular tissue, everything increases, so our density – the breast density becomes extremely dense. It is extremely difficult to find cancers in those patients. So, yes, breastfeeding does affect it.
Melanie: So, summarize it for us Dr. Tumyan. What would you like women to know about the laws about getting the letter that informs them that they have dense breast tissue and there may be slightly increased risk of cancer but still getting those mammograms on a regular basis? What would you like to tell them?
Dr. Tumyan: I want to let them know that for patients in California, when they do get the dense breasts letter; it is just something to consider and talk to your doctor and individualize your personal breast cancer screening with your physician. It should be a conversation to this and it should be a balanced discussion with your clinician to determine your overall risk factors for breast carcinoma. Once you determine your overall risk factors; then determine what additional supplemental, if any, examinations would be appropriate for you. If you are average risk; consider ultrasound, always consider 3-D tomography because that is really good for dense breasts. If you are high risk; then consider adding MRI to your screening mammogram.
Melanie: Thank you So much Dr. Tumyan for being with us today. You are listening to City of Hope Radio and for more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.