Dorothy: [00:00:00] We hear a lot about dense breasts, but what does that mean exactly? And why is it so dangerous for women when having a mammogram? Dr. Raz, our lead interpreting physician and fellowship trained radiologist, explains why women need to know the type of breast tissue they have. And what it could mean in saving their lives.
He also explains why women with dense breasts need to insist that every test available be used when having their annual mammogram. It isn’t just a recommendation anymore. Dense breasts mean you need all the testing that you can get just to be sure that that breast cancer is detected early.
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Let’s Talk About Your Breasts, a different kind of podcast presented to you by The Rose. The Breast Center of Excellence and a Texas treasure. You’re going to hear frank discussions about tough topics. And you’re going to learn why knowing about your breasts could save your life.
Fan 1: Dr. Raz, what factors influence breast density?
Dr. Raz: Okay, so it’s a multifactorial. The majority of breast density is genetic. It’s just how you’re made. I’d say probably 60 percent. And beyond that, factors are You know, obesity, so, something Dr. Melillo loves talking about. If you’re thinner, if you’re less obese, then your breasts tend to be dense. Simple reason is breast is made of fat and breast tissue. And so less fat seems like your breast is more dense, and it’s more dense. Uh, then, if you are, uh, You know, premenopausal, if you’re hormonally active, if you’re younger, you have estrogen in the body, [00:02:00] your breasts are dense. As you get older, your breast density decreases.
Um, however, if women are on hormonal replacement therapy, or, If external estrogens getting into the body, then your breast is dense. Um, so these are the type of factors that contribute to if there is increased breast density or not. But I want to be sure these are less of factors than you’re just genetic makeup. Naturally, some women just tend to have more dense breast tissue. The other factors that I explained are just Just to lower down the list.
Fan 1: How does a woman know if she has dense breasts?
Dr. Raz: So, breast density is reported on, on, uh, standard mammogram reports. In Texas, at least, we report it. There is no standard out there in the nation, uh, recommendation.
But the first line usually says if you have extremely dense breasts, heterogeneously dense breasts, Um, scattered Breasts or fatty Breasts. These are the [00:03:00] four categories. So, in the mammogram report that you’ll get in mail and your provider will, you will have that mentioned. Otherwise, on physical exam, it’s, you’re not going to be able to tell if your breasts are dense or not.
Fan 0: What are dense breasts?
Dr. Raz: Breast density refers to, so first you have to understand how the breast anatomy works and how breasts are made. Majority of breast is, is fatty. And then you have what we call fibroglandular tissue, which is made up of glands that produce milk, then ducts associated with them.
And what in medicine we call it stroma or the supporting structures. And which includes ligaments. So Cooper’s ligaments, which gives breast the shape. All of that is considered breast tissue. And then, as I mentioned, fat. So that really is the composition of breast. And on mammogram, you know, if you were to look at a mammogram, you know, if you Google mammogram, um, you’ll see a mammographic uh, picture where the white stuff is your fibroglandular breast [00:04:00] tissue and then the black stuff is your, is the fat. So breast density refers to the fact, the ratio between this where do you or do you not have a lot more of this white stuff which is what it seems on radiogram, radiograph or on mammogram which is the fibroglandular tissue versus the fat which is the radiolucent or darker stuff.
So breast density refers to this ratio and some women have a lot more breast tissue when compared to fat, versus some other women that have a lot more fatty tissue than the fibroglandular breast tissue. So, that’s really what density means in medical terms, when we mention it on their mammographic report.
Fan 0: Are dense breasts common?
Dr. Raz: Yes, so, over 40, you know, mammogram starts at 40, so, About 40 to 50 percent of the women have dense breasts that are over 40 that we do mammogram on. So it is common. Yes.
Fan 2: How is breast [00:05:00] density categorized in a mammogram report?
Dr. Raz: So we assign four categories, ABCD, and these are all standardized from the BioRADS manual that all the reports come from.
And A refers to if it’s entirely fatty breast tissue. B is scattered fibroglandular, meaning you see some fibroglandular tissue but it’s not the dominang feature. Then you get into the dense breast, which is heterogeneously dense, which is C, category C.. This is where often the mammogram reports will say this may obscure masses or other abnormalities, and again, that’s a standard reporting thing we do in every mammographic report. And the fourth category, the D, is extremely dense, which really means that majority of the breast tissue is dominated by the fibroglandular tissue or the breast tissue versus the fat.
So these are the four categories that will get reported. And if you have one of them, they’ll be the first line on the mammographic [00:06:00] report, and that’s how you know if you have dense breasts or not. Again, to be sure, if you have fatty A or B, which is fatty or scattered, it’s considered non dense, and if you have heterogeneously dense breast tissue or extremely dense breast tissue in the, in the report, that means you have dense breasts. So this, broadly you divide, divide it into non dense, dense, and then subcategories, as I mentioned, are the ABCDs.
Fan 2: Does having dense breast tissue affect a mammogram?
Dr. Raz: Having dense breast tissue does reduce sensitivity of mammogram. And, you know, women that have heterogeneously dense breasts are extremely dense breast. Yes. So sensitivity again, in medicine, sensitivity means if you do an examination or a test, are you able to catch the disease or not? And which sensitivity? So if you have high sensitivity, If some person has the disease, or in this case, cancer, does that exam capture that? Higher sensitivity tests or medical studies are very good at [00:07:00] catching what they’re intended to do.
So, we want high sensitivity. Well, unfortunately, the denser the breast, the lower the sensitivity of mammogram, and we mentioned that in the report, and the new FDA guidelines that are going to be coming out in September, they want everybody in the nation, every radiologist and medical facility to mention this.
So it’s very important. So yes, studies have proven that sensitivity of mammogram in fatty breast, scattered breast, scattered fibroglandular breast is around 85 -90%, but -that really drops to 60 -65 percent if you have Heterogeneous deaths are extremely dense breast. So yes, in that situation, we’ll have to look towards supplementary, uh, studies on top of mammogram to increase our sensitivity.
Fan 3: Are dense breasts a risk factor for breast cancer?
Dr. Raz: Yes. And the whole premise and the whole point of even mentioning what breast density a patient has in the mammogram report is [00:08:00] this fact where there’s 30 plus years of research that has been done that has proven that having Dense Breast Tissue. So again, just to summarize, non dense breast tissue is fatty or scattered fibroglandular.
It’s called non dense. And dense are the other two categories, C and D. Uh, in the standardized mammographic report, which would be heterogeneously dense or extremely dense. So, if you have any of those two, you have dense breast tissue, and yes, dense breast tissue has been proven to increase, to have increased risk of developing breast cancer.
Now, how much? Studies vary, but relative risk, meaning in the group that has dense breast tissue versus not having dense breast tissue, you run the risk of 2 to 6X. You know, the amount of risk of developing breast cancer versus not having dense breast tissue. So yes, it is an independent risk factor for developing breast cancer, which is why it’s very important to [00:09:00] know if you have dense breast or not.
Fan 3: Should women with dense breasts have additional screening for breast cancer?
Dr. Raz: Yes, so that’s a great follow up question. Again, as we established that having dense breast is an independent risk factor for having increased chance of having breast cancer, Well then, what can you do about it? Now again, there is no standard recommendation nationwide what we should do.
However, remember, the goal of screening is to catch cancers early, and if we are able to catch breast cancer early, it’s completely curable, really. A very high survivable rate, uh, on smaller cancers. And that’s really the power of screening. So, screening mammogram, um, you know, usually catches about three to four breast cancers out of a thousand that I read.
But Many studies have been done and if women start getting ultrasound, especially women with breast, dense breast tissue, ultrasounds added to, to the same cohort, then we’re able to catch three to four [00:10:00] additional cancers out of these thousands. So you can pretty much say that we have doubled our cancer detection rate.
If you were to add ultrasound, that’s just one modality. But yes, um, there is no standardized or national recommendation. However, women do benefit if you have dense breast tissue with supplementary studies, so be it ultrasound or if you are in a high risk category, then definitely MRI. So, these supplementary studies increase our sensitivity, increase our cancer detection rate to catch cancer. So, it does benefit a woman to do supplementary study on top of mammogram.
Fan 1: Dr. Raz, are breast cancer patients with dense breasts more likely to die from breast cancer?
Dr. Raz: So, studies have been done on this and it’s an active area of research, uh, but so far we have not found clear evidence where if you have dense breasts and if you have cancer, Are you more likely to die if you have lower survivability?
No, there is no [00:11:00] such indication in many of the studies. You know, again, the whole thing is if you have dense breast, a lot of sensitivity of mammogram goes down and it’s possible by the time we, and again, studies have been done that we, when we do catch cancer, it’s a little bit more advanced. It’s harder to see masses in dense breast if you don’t do ultrasound.
So definitely, you know, as we mentioned, increased risk of having, uh, breast cancer if you have dense breast. And since our sensitivity isn’t that good, by the time we catch it, it’s at a later stage. So it absolutely should do some other supplementary study on top of a mammogram. But so far, if you do get breast cancer, if you do have it, and if you have dense breast, there has been no association that your survivability is any lower.
Fan 1: Anything that you’d like to leave the women that have these type of questions, anything you’d like to say one last thing?
Dr. Raz: Listening to this podcast. Uh, we have lots of good [00:12:00] information that comes in. And, you know, dense breast is, it’s an active area of research and new FDA guidelines are coming up. So September, there every state in the nation will have to report and send a letter to the patient and the provider that does talk about the breast density, gives recommendations, and mentions that it is an independent risk factor, and then has to have some information regarding where women can get more information regarding this.
So, uh, You know, just be proactive, talk to your, uh, primary care about breast density and risk factors for developing breast cancer. And if you have any, and if you have any further questions, The Rose is always here. We’re happy to answer all your questions. Thank you.
Post-Credits: Thank you for joining us today on Let’s Talk About Your Breasts. This podcast is produced by Speke Podcasting and brought to you by The Rose. Visit therose.org to learn more about our organization. [00:13:00] Subscribe to our podcast. Share episodes with friends, and join the conversation on social media using #Let’sTalkAboutYourBreasts. We welcome your feedback and suggestions. Consider supporting The Rose. Your gift can make the difference to a person in need. And remember, self care is not selfish. It’s essential.