Transcription:
Breast Density

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And this is the Well Within Reach podcast. I’m Alyssa Diaz, and joining us today is Dr. Brian Ruiz de Luzuriaga and he’s a radiologist here at Riverside Healthcare. Welcome, Dr. Brian. Thanks for joining us.

Dr. Brian Ruiz de Luzuriaga (Guest): Thank you so much for having me today.

Host: Today’s topic covers breast density, but before we get into the topic, let’s talk about your role as a radiologist and kind of how that relates to breast health.

Dr. Ruiz de Luzuriaga: So sure, yeah, I’m a radiologist here at Riverside Medical Center. I’ve been here at the hospital for about 2.5 years now, and as radiologists for our role in the Breast Imaging Center is we’re the ones who provide the interpretation for the various imaging tests that patients would have from mammograms to ultrasounds to MRIs and we – particularly for the screening programs, screening mammography, that’s probably the most common experience that patients will have with the imaging center to come in, we provide those interpretations, and then we also help provide biopsies and tissue diagnosis for patients who have suspicious findings on their imaging tests.

Host: Okay, and going right into those imaging tests, there is a new amendment that requires that if a patient’s mammogram demonstrates dense breast tissue, the provider of the mammography service must provide notice to the patient, which can spark many questions and concerns for patients. So we’re here to discuss dense breast tissue and give everyone a better understanding should they, or a loved one, receive this diagnosis. So dense breasts, what does it mean?

Dr. Ruiz de Luzuriaga: So yeah, let’s go back and talk about how this all came about. It’s actually a very interesting example of how patient advocacy groups can really affect the way we deliver health care. So a lot of these initiatives began in 2009. Connecticut was the first state to have one of these dense breast notification laws. So there was an organization started by a Dr. Nancy Cappello and she was a PH.D who had the experience of going in every year for her screening mammograms and every year coming away with a normal exam, and then was suddenly shocked one year when she was diagnosed with an advanced stage breast cancer, it was stage IIIc, and so she formed a group called areyoudense.org that helped educate women about the issue of dense breast tissue. More and more states have gone – have passed laws to help notify women about the density of their breasts. So here in Illinois, HB4392 was passed last year and went into effect January 1 of this year, and so there’s two components to the state law really; 1) requires that the mammography providers notify women about the dense breast tissue and its effect on the accuracy of mammograms, and 2) encourages the patients to discuss the issue with their healthcare providers. So when we talk about dense breast, really the way to think about it is, if you’re looking at maybe the sun or the moon in the sky and you can think of it to having a completely clear sky to partly cloudy, mostly cloudy, to completely overcast, and so breast tissue works sort of in the same way the clouds do, in that you see the breast tissue as white on the background of the fatty tissue, which is darker. So that white tissue, like the clouds can kind of obscure masses that we may be looking for in the breast tissue. So it’s something that was always known for radiologists to be an issue for making diagnosis, but really these laws, the point of them, is to help make the patients more aware of the results of their imaging tests and the possible ramifications for them.

Host: So when a patient receives this letter, it’s not necessarily bad news, scary news, it’s more to empower the patient so that they understand what this could mean and it kind of gives them that education on their diagnosis, so that they understand, this is what it could mean, this is how you understand what having a dense breast tissue means for a patient.

Dr. Ruiz de Luzuriaga: Right, and again it’s very much because of patient advocacy groups and women’s groups who want to know this information so that they can better able to potentially make other choices for what they may need to do for screening. Now the other thing that’s interesting that should really be noted about breast density is that right now we don’t really have the medical research available out there that tells us exactly what we should do with women who have these dense breasts, and we can talk about that a little later on, but right now it does pose some challenges when you’re referring to women getting these letters now and suddenly having this question mark, what are they supposed to do from here?

Host: So is there a cause for dense breast tissue? What does that mean if somebody is told that they have dense breasts? Where does it come from?

Dr. Ruiz de Luzuriaga: Right, so it’s normal to have glandular tissue in the breasts, and it varies amongst women in the population. So as it turns out, about half the women in the population have what are considered to be dense breasts, and so if you take a look at population based data from the National Cancer Institute for example, the percentage of women who have heterogeneously dense breasts, which means about 50% to 75% dense, that’s about 39% of the population, and those with extremely dense breasts, that’s another 10%, and so if you take a look at women between the ages of 40 to 74 in the US, that’s over 27 million women who are going to have dense breasts. In comparison those with fatty breasts, where is a small amount of glandular tissue and it’s mostly fatty, that’s only about 10% of the population, and then everyone else is kind of the scattered fibroglandular tissue. So things that cause it – so typically younger women will have more dense breasts than older women. Below the age of 50, over half of women will have dense breasts, as opposed to after the age of 70 when it’s less than 30%. Your weight can affect the density of the breast tissue as well. Typically, those with higher BMIs, body mass indexes, will have less dense breasts than women with lower BMIs. Hormone replacement therapy can also effect breast density as well.

Host: Okay, if you have dense breast tissue, does that mean you have dense tissue in other parts of your body, and what does that mean as a patient?

Dr. Ruiz de Luzuriaga: So really again, the importance of dense breasts is really specific to screening mammography where we’re trying to examine the breast tissue itself to look for cancers. So it doesn’t really apply or have very much importance to other parts of the body.

Host: Okay, and those things that you mentioned that may be a causing factor, looks like lifestyle changes can affect some of that. If we’re eating right, exercising, things like that, does that seem to make a difference for patients? Is this something that can improve over time?

Dr. Ruiz de Luzuriaga: So I think the thing to – the other thing that’s important to know about having dense breasts, besides it causing difficult in examining the breast tissue, there’s also research that shows it’s, in and of itself, a risk factor for breast cancer. So as it turns out, if you look at women who have the heterogeneously dense breasts, if you compare those to women who are scattered fibroglandular tissue, their risk of breast cancer is about 1.2, relative risk. If we say something has a relative risk of 1, that means it’s the same as the average population. So it’s slightly higher, and then if you have very dense – extremely dense breasts, then the relative risk is 2.1, but to put that into context, that’s the same as some other risk factors for possibly – for breast cancer. For example, having two drinks of alcohol a day compared to a nondrinker, that’s a relative risk of about 1.2. If you’re on hormonal replacement therapy or currently using oral conceptive pills, your relative risk is about 1.3. Now if you compare that to other things that we think about as having higher risks of breast cancer, for example, say family history, if you have two first degree relatives with breast cancer, now you’re up to about 3.6 to 3.8. If you have a gene mutation, such as one of the BRCA genes, you’re talking about a 200 fold increased risk. So dense breasts do have some importance, but it’s not necessarily the most critical thing, and as you were saying there’s a lot of other issues that you may actually be able to change in your lifestyle with respect to drinking alcohol, losing weight, not being on hormonal replacement therapy, things like that that could actually decrease your risk for breast cancer.

Host: As a radiologist, how does dense breast tissue affect one’s testing?

Dr. Ruiz de Luzuriaga: Sure, so and again, that’s kind of what we were getting back to before, that having that dense breast tissue there, can make it difficult to see in the tissue. So again if you have a spot that there in the breast, or a mass if you will, having that extra glandular tissue can make it more challenging to see.

Host: Are there any tests better than a mammogram for dense breasts?

Dr. Ruiz de Luzuriaga: So there are additional tests that we use as supplemental screening. So it’s always important to remember that screening mammography is the only imaging modality that’s been shown to decrease risk of mortality from breast cancer. So by undergoing either annual screening o screening every other year, you decrease the risk of death – the relative risk of death is decreased to 0.8, so it’s very important. Now, things that can help seeing in the dense breast tissue, first of all a lot of the literature that was talking about the decreased sensitivity was talking about some of the older mammograms that we used to do where it was film screen mammography. So most centers these days now do use digital mammography, which has helped raise sensitivity for detecting breast cancer even in women with dense breasts. So it brings it almost to the same level of sensitivity that we used to have with the film screen mammograms for women who were scattered fibroglandular tissue. Other things that have been added to a lot of screening programs is breast tomosynthesis or 3D mammography. So that’s also very important in women who have dense breasts. It helps women of all breast densities, but certainly in those who have more dense tissue, ti helps to be able to see in that tissue because you’re taking – basically it’s like having a 3D slice through it where you’re cutting through the breast, so you can see things that would otherwise be hidden. So it turns out by adding on tomosynthesis or 3D mammography, you can detect another 1 to 2 cancers per 1,000 women just by using that, so it’s been very helpful. There also other modalities that involve using ultrasound, so we can use whole breast screening ultrasound, either where the technologist or the physician does the scanning themselves. They also have automated systems now where the scanner automatically performs the scans through the breast tissue. That’s been the workhorse for a lot centers as well where it’s fairly accessible to women and it’s pretty well tolerated. So using breast screening ultrasound, you can find additional cancers there as well, maybe another 4 or so per 1,000 women. The problem with ultrasound and some of the other supplemental screening studies that we’ll talk about later is that you can also find other things that aren’t breast cancer, and so that can also become a concern for women about coming in for all these additional tests, finding other things that in the end really have no affect on their longevity, meaning we’re not finding breast cancers or we’re not finding things that are going to shorten their life if we were just to find them later. Breast MRI is another modality that can be used. Typically that’s one that’s really reserved more for our high risk population, one who’s got a lifetime risk of say over 20%, 25% or has a personal history of breast cancer. There’s some other modalities that we can also use including molecular breast imaging. That’s not necessarily widely available in clinical practices. That’s more university centers that may be offering it, and then down the road, there may be other things that will be helpful as well such as contrast enhanced mammography where we would actually inject again some intravenous contrast and then taking images of the breast. Again, not something that’s widely clinically available, but perhaps something in the future.

Host: And at any rate, early detection’s key first stop is your annual mammogram. So if you are of the age to receive annual mammograms, making sure that you’re staying on top of those, and then working with your healthcare team to understand what dense breast tissue means and what next steps may be for you as a patient.

Dr. Ruiz de Luzuriaga: Absolutely, absolutely and that’s a question that we can from women very commonly who for whatever reason, might have difficulty doing the mammograms or the concerns over having the breast and compression, things like that, all of these other imaging tests that we’re talking about are always in addition to, but not to replace mammography. Because again, screening mammography is really the only imaging test where we have good scientific evidence that it reduces death from breast cancer. In fact, on my way in this morning I just heard about a new article that was published in Cancer that talked about looking at women who’ve been treated since the early 90s, I think it’s from about ’89, taking into account the screening programs that we do now for mammography and also the newer imaging tests, the estimates – excuse me, the new treatment methods that is – the estimates are that it’s saved around 500,000 women from breast cancer death.

Host: That’s pretty incredible, and new technologies like the 3D mammograms and all of these modalities that you mentioned are just really important to women, and let’s take that proactive step forward and caring for yourself and caring for your loved ones as well.

Dr. Ruiz de Luzuriaga: That’s right, it kind of shows the importance of continuing to do this research. As I said, we need to do the tests to figure out are these supplemental tests for the dense breast screening. Is that going to give benefit to women in terms of further decreasing their risk of death from breast cancer? So it’ll be exciting to see over the coming years and how we can further – further save patient’s lives.

Host: Well thank you for giving us a better understanding of what breast density is and what it means for a patient. If individuals are looking for more information on dense breast tissue, definitely talk to your doctor first and your healthcare team, that’s always a good first step. Also you can find more information online at riversidehealthcare.org or at acr.org, and Dr. Brian do you have other resources to share with us?

Dr. Ruiz de Luzuriaga: No those are good ones, but one thing that I do want to talk about before we end our conversation today is that the group of women who are going to want to consider additional testing outside of the screening mammography and the tomosynthesis, are really going to be the women who fall into what we consider more of an intermediate risk for breast cancer, and so what we’re talking about there are women with about a 15% to 20% lifetime risk, if you’ve gone through and had those estimates taken, a personal history of breast cancer, a history of lobular neoplasia, or atypia on a prior biopsy; those are the women where possibly doing the whole breast screening ultrasound may add some value. If you have no other risk factors really other than just having the dense breasts, there’s really no recommendations that you consider doing any supplemental screening other than just the mammography, and finally if you fall into the high risk category where you’re over 20% and 25%, again MRI is really the way to go. So that’s going to be something that’s going to want to be incorporated in with the screening mammography. These are all things, as you said to talk with your physician about or with a radiologist when you come in for your screening exams. Again, it’s just one other component to be aware about and we look forward to helping women navigate this process as they come to us.

Host: Well thank you, thank you for joining us and that wraps up this Well Within Reach Podcast for Riverside Healthcare.