October is Breast Cancer Awareness Month and this year, the focus is on breast density. Breast density describes the proportion of the different tissues that make up a woman’s breasts. On a mammogram, the areas of breast and connective tissue seen are compared to the area(s) of fat.
Breast and connective tissue are denser than fat and this difference shows up on a mammogram High breast density means there is a greater amount of breast and connective tissue compared to fat.
Low breast density means there is a greater amount of fat compared to breast and connective tissue.
Here to talk about breast density, mammograms and other ways of imaging dense breasts as well as the new law requiring information on breast density to be sent to women is John Cunningham, M.D., Director of the Summit Medical Group Breast Care Center.
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What Women Need to Know About Breast Density
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John D. Cunningham, MD
John D. Cunningham, MD, is Medical Director of the Summit Medical Group Breast Care Center. In addition to his position at Summit Medical Group, Dr. Cunningham is Attending Surgeon for Overlook Medical Center in Summit, New Jersey. He is Assistant Clinical Professor of Surgery at Columbia College of Physicians and Surgeons in New York City. He was previously Assistant Professor of Surgery for Mount Sinai Medical Center in New York City. A gifted speaker, Dr. Cunningham has delivered local, regional, and national invited presentations concerning a wide range of topics in surgical oncology. Dr. Cunningham is a recipient of more than 20 honors and awards, including the American College of Surgeons Commission on Cancer Outstanding Cancer Liaison Award and Overlook Medical Center Clinical Excellence Physician Award. He has been featured in the Castle Connolly "Top Doctors: New York Metro Area" and "America's Top Doctors" listings as well as the Consumer Research Council of America "America's Top Surgeons," New Jersey Life "Top Doctors for Women," and New Jersey Monthly "Top Doctors" listings. Dr. Cunningham's top doctor listings have been reprinted in US News and World Report and Inside Jersey.Learn more about Summit Medical Breast Care Center
Transcription:
What Women Need to Know About Breast Density
Melanie Cole (Host): When you had your last mammogram, your report may have said that you have dense breast tissue and you’re probably wondering what this means. My guest today is Dr. John Cunningham. He is the medical director of the Summit Medical Group Breast Care Center. Welcome to the show, Dr. Cunningham. Tell us first of all, what is dense breast tissue?
Dr. John Cunningham (Guest): Well, dense breast tissue is a ratio of the fatty tissue within the breast, compared to the amount of breast and connective tissue. Why that is important is that the fatty tissue is very easy to image and the x-ray penetrates that very well and allows you to read the mammogram very easily. When the breasts become more dense and there is more breast tissue and more connective tissue, the x-ray does not penetrate that tissue as well, and there can be some problems reading the mammogram as a woman’s breast density increases.
Melanie: How do we know if we have dense breasts?
Dr. Cunningham: As a patient, for the most part, you would not know. Sometimes in self-examination, you will be able to feel the breast feels very firm and hard, but again, comparatively, you may not have an idea what your density would be to somebody else. The new Breast Density Law now states that we need to discuss with patients breast density and so that is a discussion you could have with your primary care physician or whoever orders your mammogram.
Melanie: Breast density is important and this law was enacted because…?
Dr. Cunningham: Yeah, the law was enacted to educate the general public about breast density. Now, breast density is not a new entity as far as the physicians are concerned. It’s been around forever. Your breast density has not changed from your mammogram probably two years ago to the mammogram you’re getting now, but you’re getting a letter talking about your breast density. I think that’s created a lot of anxiety for women because they don’t understand exactly what breast density is, but the law was enacted to educate the general public about two concerns with breast density. The first, as I kind of stated with the definition, is that as the breast becomes more dense, it may be harder to read or interpret a mammogram, and that is a small factor, but it is possible. Because of that, we may miss something on the mammogram and that we missed maybe benign or could be a malignant cancer. Secondly, there’s a slight increase as a woman’s breast density goes up for that woman to develop breast cancer, but that increases pretty much in the top 10% of people who have the most dense breasts.
Melanie: If we keep in mind that breast density is only one of the many factors that can affect our chance of breast cancer, what do you say to women that are a little bit anxious when they get that letter? I received that letter, Dr. Cunningham, and I’m not anxious about it because it’s just one more thing.
Dr. Cunningham: Yeah, I think in the realm of risk factors, breast density is low on the risk factor list that I get concerned about. Family history, genetic history, previous breast cancers in the person or biopsies that show atypical changes are all much more important in a risk factor stratification than breast density. But because patients are getting this letter, there is an increase in anxiety. The law does cover any further imaging that may be needed based on breast density – if you need an ultrasound or MRI – but neither of those tests has been shown to be effective in screening the general public. Those are tests that are better to screen women with either extremely dense breasts or significant risk history for breast cancer.
Melanie: Would a woman who gets that letter want to ask her doctor about getting ultrasounds or MRI in addition to our mammogram? Tell us a little bit about how dense breasts affect the mammogram and whether we should be asking about other tests.
Dr. Cunningham: Yeah. As I said, the law will cover any further imaging that’s warranted based on the imaging changes. The breast density is usually divided into quartiles, 25% dense, 25% to 50%, 50% to 75%, and greater than 75%. As I said, the women who fall into that greater than 75% density, which is only about 10% of women, so 90% of women don’t need really to worry about that, but that top 10% probably should see a breast specialist. That breast specialist would review, obviously, the patient’s physical exam, the patient’s mammogram, and do a risk assessment to determine what that patient’s risk is going forward to develop breast cancer, and based on all of those, would decide then – does the patient need an ultrasound, an MRI, both, or maybe no further imaging?
Melanie: You know, women have been doing self-exams for quite a while, Dr. Cunningham. Does dense breast tissue affect our ability to give ourselves that self-exam and possibly find something very early?
Dr. Cunningham: I think the more dense a woman’s breast is, not only they’re harder to image, but it’s also harder to do a self-exam. Based on that, I would not tell patients not do a self-exam if your breasts are more dense. It’s still very important to do a self-exam. Studies have shown breast self-exam help find things that may not show up in a mammogram, or that would be superficial or underneath the skin and that maybe easily palpable. Yes, it is a little harder to do a breast self-exam based on increasing breast density. I would still recommend patients to do a breast self-exam. I think it’s very helpful.
Melanie: Does breast density mask cancers? We’ve discussed the definition a little bit, but we get this letter and I’m trying to reduce anxiety here for women. Does it typically mask or…? The technology today is so good that you doctors can really find these things.
Dr. Cunningham: Yeah. I think a bunch of the studies that had been done before with breast density had been done with standard, what was called analog mammography. We moved from analog mammography now into digital mammography, which will give a much better picture of a woman’s dense breasts than the old analog technique. Already, we’ve moved one step ahead. Recently, a couple of companies have come up with what’s now called tomosynthesis, or 3D mammography, where it’s multiple images taken of the breast, and that 3D imaging has been shown to be superior to even digital imaging, especially in women with dense breasts. I think we’re making some good technological advances for imaging purposes. But there are still some cancers that will be masked or not seen as well in somebody with extremely dense breast tissue, as we mentioned, compared to someone with fibro-fatty or mostly fatty breast tissue.
Melanie: Dr. Cunningham, besides breast density, what can a woman do to reduce her risk of breast cancer?
Dr. Cunningham: The major risk factors, we really have no control over: family history, history of previous biopsy showing atypia. There are some risk factors that you could control - when you have your first child - but again, I don’t see people rushing out at age 18 or 21 to have a child to reduce the breast cancer risk. The majority of risk factors that we see and are most important in the stratification of risk, we really have no control over.
Melanie: Are there ones that we do have control over?
Dr. Cunningham: Yeah, probably the two things that can be very helpful, and not only just for breast health but overall health, are obviously, good nutrition, balanced diet, making sure you’re not overweight; secondly, probably reducing alcohol intake. For average woman, one drink a day would be maximum, anything more than that may increase your risk for developing breast cancer.
Melanie: Is dense breast tissue genetic?
Dr. Cunningham: I don’t think it’s genetic. There are often women who have dense breast tissue whose offspring will not, so it’s not genetically related. There are some genes that we know are associated with breast cancer risk, but that has nothing to do with breast density.
Melanie: Dr. Cunningham, in just the last few minutes, give the listeners your very best advice if they should find out, or if they do find out, that they have dense breast tissue and why they should come to Summit Medical Group for their breast care.
Dr. Cunningham: I think the most important thing to tell the general public is this letter that is coming out has been mandated by the state in New Jersey. Therefore, we’re trying to educate the population about the two major risk factors for breast density: the possibility of missing something on the mammogram and the increased risk for developing breast cancer. Again, that risk falls mostly in the top 10% of women’s density. It doesn’t affect most women. I think that’s the most important part of this discussion. Secondly is that, as I stated earlier, a woman’s density is unchanged based on receiving this letter. They’re breasts were dense five years ago, four years ago, three years ago in the mammogram. Therefore, as physicians are well aware of this breast density issue, we’ve been ordering ultrasound and other imaging as needed based on density in the past. The law is more, I think, to educate the general public. It’s important for the general public to know we’re very aware of the density issue and if there is anything on the mammogram that would warrant further imaging, a physician would order that. I think coming to the Summit Medical Group would be a very good idea. We have several breast surgeons here who do only breast surgery and are involved in breast disease. I think we’re very up-to-date on the physical examination, the risk stratification, and the review of the mammography. We have just been approved here to get our 3D tomosynthesis, which is the technology I talked about with mammography that will show better images for women with dense breast. I think based on the fact that we have a breast center here, we have an excellent imaging center, people would be well treated if they came to the Summit Medical Group.
Melanie: Thank you so much, Dr. John Cunningham. You’re listening to SMG Radio. For more information, you can go to summitmedicalgroup.com. That’s summitmedicalgroup.com. This is Melanie Cole. Thanks for listening.
What Women Need to Know About Breast Density
Melanie Cole (Host): When you had your last mammogram, your report may have said that you have dense breast tissue and you’re probably wondering what this means. My guest today is Dr. John Cunningham. He is the medical director of the Summit Medical Group Breast Care Center. Welcome to the show, Dr. Cunningham. Tell us first of all, what is dense breast tissue?
Dr. John Cunningham (Guest): Well, dense breast tissue is a ratio of the fatty tissue within the breast, compared to the amount of breast and connective tissue. Why that is important is that the fatty tissue is very easy to image and the x-ray penetrates that very well and allows you to read the mammogram very easily. When the breasts become more dense and there is more breast tissue and more connective tissue, the x-ray does not penetrate that tissue as well, and there can be some problems reading the mammogram as a woman’s breast density increases.
Melanie: How do we know if we have dense breasts?
Dr. Cunningham: As a patient, for the most part, you would not know. Sometimes in self-examination, you will be able to feel the breast feels very firm and hard, but again, comparatively, you may not have an idea what your density would be to somebody else. The new Breast Density Law now states that we need to discuss with patients breast density and so that is a discussion you could have with your primary care physician or whoever orders your mammogram.
Melanie: Breast density is important and this law was enacted because…?
Dr. Cunningham: Yeah, the law was enacted to educate the general public about breast density. Now, breast density is not a new entity as far as the physicians are concerned. It’s been around forever. Your breast density has not changed from your mammogram probably two years ago to the mammogram you’re getting now, but you’re getting a letter talking about your breast density. I think that’s created a lot of anxiety for women because they don’t understand exactly what breast density is, but the law was enacted to educate the general public about two concerns with breast density. The first, as I kind of stated with the definition, is that as the breast becomes more dense, it may be harder to read or interpret a mammogram, and that is a small factor, but it is possible. Because of that, we may miss something on the mammogram and that we missed maybe benign or could be a malignant cancer. Secondly, there’s a slight increase as a woman’s breast density goes up for that woman to develop breast cancer, but that increases pretty much in the top 10% of people who have the most dense breasts.
Melanie: If we keep in mind that breast density is only one of the many factors that can affect our chance of breast cancer, what do you say to women that are a little bit anxious when they get that letter? I received that letter, Dr. Cunningham, and I’m not anxious about it because it’s just one more thing.
Dr. Cunningham: Yeah, I think in the realm of risk factors, breast density is low on the risk factor list that I get concerned about. Family history, genetic history, previous breast cancers in the person or biopsies that show atypical changes are all much more important in a risk factor stratification than breast density. But because patients are getting this letter, there is an increase in anxiety. The law does cover any further imaging that may be needed based on breast density – if you need an ultrasound or MRI – but neither of those tests has been shown to be effective in screening the general public. Those are tests that are better to screen women with either extremely dense breasts or significant risk history for breast cancer.
Melanie: Would a woman who gets that letter want to ask her doctor about getting ultrasounds or MRI in addition to our mammogram? Tell us a little bit about how dense breasts affect the mammogram and whether we should be asking about other tests.
Dr. Cunningham: Yeah. As I said, the law will cover any further imaging that’s warranted based on the imaging changes. The breast density is usually divided into quartiles, 25% dense, 25% to 50%, 50% to 75%, and greater than 75%. As I said, the women who fall into that greater than 75% density, which is only about 10% of women, so 90% of women don’t need really to worry about that, but that top 10% probably should see a breast specialist. That breast specialist would review, obviously, the patient’s physical exam, the patient’s mammogram, and do a risk assessment to determine what that patient’s risk is going forward to develop breast cancer, and based on all of those, would decide then – does the patient need an ultrasound, an MRI, both, or maybe no further imaging?
Melanie: You know, women have been doing self-exams for quite a while, Dr. Cunningham. Does dense breast tissue affect our ability to give ourselves that self-exam and possibly find something very early?
Dr. Cunningham: I think the more dense a woman’s breast is, not only they’re harder to image, but it’s also harder to do a self-exam. Based on that, I would not tell patients not do a self-exam if your breasts are more dense. It’s still very important to do a self-exam. Studies have shown breast self-exam help find things that may not show up in a mammogram, or that would be superficial or underneath the skin and that maybe easily palpable. Yes, it is a little harder to do a breast self-exam based on increasing breast density. I would still recommend patients to do a breast self-exam. I think it’s very helpful.
Melanie: Does breast density mask cancers? We’ve discussed the definition a little bit, but we get this letter and I’m trying to reduce anxiety here for women. Does it typically mask or…? The technology today is so good that you doctors can really find these things.
Dr. Cunningham: Yeah. I think a bunch of the studies that had been done before with breast density had been done with standard, what was called analog mammography. We moved from analog mammography now into digital mammography, which will give a much better picture of a woman’s dense breasts than the old analog technique. Already, we’ve moved one step ahead. Recently, a couple of companies have come up with what’s now called tomosynthesis, or 3D mammography, where it’s multiple images taken of the breast, and that 3D imaging has been shown to be superior to even digital imaging, especially in women with dense breasts. I think we’re making some good technological advances for imaging purposes. But there are still some cancers that will be masked or not seen as well in somebody with extremely dense breast tissue, as we mentioned, compared to someone with fibro-fatty or mostly fatty breast tissue.
Melanie: Dr. Cunningham, besides breast density, what can a woman do to reduce her risk of breast cancer?
Dr. Cunningham: The major risk factors, we really have no control over: family history, history of previous biopsy showing atypia. There are some risk factors that you could control - when you have your first child - but again, I don’t see people rushing out at age 18 or 21 to have a child to reduce the breast cancer risk. The majority of risk factors that we see and are most important in the stratification of risk, we really have no control over.
Melanie: Are there ones that we do have control over?
Dr. Cunningham: Yeah, probably the two things that can be very helpful, and not only just for breast health but overall health, are obviously, good nutrition, balanced diet, making sure you’re not overweight; secondly, probably reducing alcohol intake. For average woman, one drink a day would be maximum, anything more than that may increase your risk for developing breast cancer.
Melanie: Is dense breast tissue genetic?
Dr. Cunningham: I don’t think it’s genetic. There are often women who have dense breast tissue whose offspring will not, so it’s not genetically related. There are some genes that we know are associated with breast cancer risk, but that has nothing to do with breast density.
Melanie: Dr. Cunningham, in just the last few minutes, give the listeners your very best advice if they should find out, or if they do find out, that they have dense breast tissue and why they should come to Summit Medical Group for their breast care.
Dr. Cunningham: I think the most important thing to tell the general public is this letter that is coming out has been mandated by the state in New Jersey. Therefore, we’re trying to educate the population about the two major risk factors for breast density: the possibility of missing something on the mammogram and the increased risk for developing breast cancer. Again, that risk falls mostly in the top 10% of women’s density. It doesn’t affect most women. I think that’s the most important part of this discussion. Secondly is that, as I stated earlier, a woman’s density is unchanged based on receiving this letter. They’re breasts were dense five years ago, four years ago, three years ago in the mammogram. Therefore, as physicians are well aware of this breast density issue, we’ve been ordering ultrasound and other imaging as needed based on density in the past. The law is more, I think, to educate the general public. It’s important for the general public to know we’re very aware of the density issue and if there is anything on the mammogram that would warrant further imaging, a physician would order that. I think coming to the Summit Medical Group would be a very good idea. We have several breast surgeons here who do only breast surgery and are involved in breast disease. I think we’re very up-to-date on the physical examination, the risk stratification, and the review of the mammography. We have just been approved here to get our 3D tomosynthesis, which is the technology I talked about with mammography that will show better images for women with dense breast. I think based on the fact that we have a breast center here, we have an excellent imaging center, people would be well treated if they came to the Summit Medical Group.
Melanie: Thank you so much, Dr. John Cunningham. You’re listening to SMG Radio. For more information, you can go to summitmedicalgroup.com. That’s summitmedicalgroup.com. This is Melanie Cole. Thanks for listening.