Celebrating World Dense Breast Day: Raising Awareness and Advocacy of Dense Breasts

World Dense Breast Day emphasizes the need for awareness and advocacy for individuals with dense breasts, which can negatively impact mammogram results and increase breast cancer risk. | Image Credit: Nadezhda Buravleva - stock.adobe.com

This year marks the second annual World Dense Breast Day on Wednesday, September 25, 2024.¹ For the past 2 years, the last Wednesday in September has been added to the National Day Calendar to bring awareness, advocacy, and education about dense breasts. The national holiday was coined by the Dense Breast Info website to communicate with patients, health providers, and health organizations around the world.²

Breast density has been found to significantly impact mammography visualization and can be the strongest, most consistent factor for breast cancer.³ Typically, breast density is defined as the percentage of the breast composed of glandular and connective tissue relative to fatty tissue. Higher levels of breast density are linked to false-negative and false-positive mammogram results, elevating the risk of breast cancer as well.⁴

In 2009, Connecticut became the first state in the US to pass legislation that mandates patients who receive screenings to be informed if they have “dense” or “not dense” breasts. Last week, national legislation went into effect that requires all US mammography facilities to provide women with information on their breast density following a breast screening.⁵

It has become important for patients to be notified and educated about breast density because it empowers them to be more involved in decision-making and treatment methods, increasing awareness about breast density and the implications it may have on breast screening.⁴ Additionally, breast density awareness and knowledge is limited among lower socioeconomic, racially diverse, and ethnic minority women who have higher levels of personal and structural barriers to access, screening, and follow-up care.

Educational Awareness

Breast density awareness is crucial knowledge for populations susceptible to breast cancer because of the affects it has on common breast screening techniques.⁴ The accuracy of mammograms relies heavily on breast density and without patient or provider knowledge of this, biennial screenings may not be performing proper preventive care.⁶ Breast density has been categorized into 4 categories, from least fibroglandular tissue to the most, labeled as category A (fatty), B (scattered), C (heterogeneously dense), and D (extremely dense).

A clinical survey data cohort of predominately Hispanic, Spanish-speaking immigrants from New York who were undergoing screening mammography were asked about their knowledge and awareness regarding breast density.⁴ About 80% of the patient population were aware of the breast cancer detection effect of dense breasts but only 50.9% were aware of the impact dense breasts had on cancer risk. More than half of the surveyed participants had personal breast density awareness (53%) while dense breast notification was found among 67% of women.

Around 21% of patients reported they initiated the topic of breast density with their health care providers and only 15% reported being informed about their breast density through a letter with their mammography results. The study participants who were directly informed about their personal density positively impacted their knowledge surrounding the impact breast density has on cancer risk and detection. The referenced study highlights the awareness this minority population has surrounding breast density and emphasizes how further education could continuously benefit patients’ overall risk and survival rates.

Awareness about breast density allows patients to recognize their mammograms are more likely to display false-positives and/or false-negatives. False-positive results on a mammogram have an increased likelihood among women with dense breasts. This can insight a sense of false security between patients who believe they are cancer free. On the other hand, false-positive results can be just as harmful as false-negatives. Around half of the women who receive an annual mammogram over a 10-year period will come across a false-positive in their lifetime. The chances of a false-positive result increase when women are younger, have dense breasts, have had previous breast biopsies, a family history, or if they are taking estrogen.

Lydia Pace, MD, MPH, associate professor at Harvard Medical School, Brigham and Women's Hospital, stated in an interview with The American Journal of Managed Care^® (AJMC^®), “Psychologically, I think it's really important for patients to be prepared that this is a likely outcome and having an abnormal mammogram does not necessarily mean that they're going to end up with a cancer diagnosis.”

The more patients are aware of false-positives and false-negatives, the more likely they will follow up on screenings. It can become difficult for patients to return for additional testing after their initial breast screening exam but the more often patients return, the greater number of screenings physicians have on hand.

Wendie Berg, MD, PhD, FACR, professor of radiology at Magee-Womens Hospital and the University of Pittsburgh, said in an interview with AJMC, “It’s important to keep in mind, women who are brought back for additional testing, it's about 10% of the time overall. The very first time we look at women who are called back for additional testing, 95% of the time it's not going to be cancer.”

Despite faults in mammography screening regarding dense breasts, it remains vital for patients to receive consistent breast screenings because this will allow them to recognize the level of density they have. Once patients are aware of their breast density, educational resources and materials can lead them to decision-making techniques that can be tailored to the patient while adding to the prevention methods.

Patient Advocacy

Once patients are informed about breast density and are aware if they have dense breasts, it is beneficial for them to practice self-advocacy. Physicians and health care specialists are knowledgeable about dense breasts, but patients have authority to express concerns regarding breast imaging based on awareness of density, family history, or other contributing factors.

Berg explained her experience with dense breast screening during a virtual media summit on dense breast reporting, saying, “My mammogram at 2D and 3D with tomosynthesis was no better at finding the small cancer that was easily seen on a contrast enhanced MRI. I asked my provider for a prescription for the MRI and was able to get it but when I asked for it, he said, ‘Tell me why you want this.’”⁵

If Berg neglected to follow up with her provider, it is possible the breast cancer would have remained undetected until it advanced. Patient advocacy can assist in treatment and extension of life but often patients are intimidated and fall short on speaking up. In a focus group study, women reported they wanted to be informed about their mammography breast density, but also expressed ambiguity about what they would do with the information once they were informed.⁷

Patients have the option to request additional screening techniques based on the negative impacts breast density has on mammographic performance.⁶ Digital breast tomosynthesis is a digital mammographic technique that differs from a traditional screening because it delivers 3-dimensional images rather than 2-dimensional. Additionally, ultrasounds, molecular breast imaging, and contrast-enhanced mammography have all showed improved cancer detection in dense breasts when compared with 2-dimensional digital mammography.

Harold J. Burstein, MD, PhD, clinician and clinical investigator at Dana-Farber Cancer Institute and Brigham and Women's Hospital in the breast oncology center, said in an interview with AJMC, “Another really important point is that we worry a lot about false positives or overdiagnosis, but some of that can be addressed through systematic changes in the way people actually have a mammogram.”

Burstein acknowledged that dense breasts and false-positives can be followed up with additional screening techniques. However, there are concerns surrounding the cost-effectiveness of these screening methods, especially among underserved populations. Some experts have suggested digital breast tomosynthesis could be cost-effective for patients if insurance companies had lower reimbursement rates, but the current US health care system would need to further explore and implement this.⁸

The financial burdens of additional screenings for dense breasts pose a significant challenge that demands ongoing attention. While the recent legislation requiring mammography facilities to inform patients of their breast density is a crucial step, it's essential to advocate for further advancements in insurance coverage and affordability. Patients can be empowered to take control of their breast health and improve early detection rates by having access to necessary screenings and follow-up care, regardless of their financial situation. As World Dense Breast Day draws closer, all health care stakeholders should remain committed to driving progress in this area and ensuring that every individual can prioritize their well-being.

References

1. World Dense Breast Day. DenseBreast-info, Inc. September 23, 2022. Accessed September 17, 2024. https://densebreast-info.org/world-dense-breast-day-september/
2. First-ever #WorldDenseBreastDay event to promote education about dense breasts. News release; DenseBreast-info, Inc. September 21, 2022. Accessed September 17, 2024. https://densebreast-info.org/wp-content/uploads/2023/01/DBI-WDBD-release-final.pdf
3. Oppong BA, Dash C, O'Neill S, et al. Breast density in multiethnic women presenting for screening mammography. Breast J. 2018;24(3):334-338. doi:10.1111/tbj.12941
4. Austin JD, Agovino M, Rodriguez CB, et al. Breast density awareness and knowledge in a mammography screening cohort of predominantly Hispanicwomen: does breast density notification matter? Cancer Epidemiol Biomarkers Prev. 2021;30(10):1913-1920. doi:10.1158/1055-9965.EPI-21-0172
5. ‌Santoro C. Breast density disclosure now mandated for mammograms. AJMC. September 10, 2024. Accessed September 17, 2024. https://www.ajmc.com/view/breast-density-disclosure-now-mandated-for-mammograms
6. Berg WA, Rafferty EA, Friedewald SM, Hruska CB, Rahbar H. Screening algorithms in dense breasts: AJR expert panel narrative review. AJR Am J Roentgenol. 2021;216(2):275-294. doi:10.2214/AJR.20.24436
7. Klinger EV, Kaplan CP, St Hubert S, Birdwell RL, Haas JS. Patient and provider perspectives on mammographic breast density notification legislation. MDM Policy Pract. 2016;1(1):1-8. doi:10.1177/2381468316680620
8. Lowry KP, Trentham-Dietz A, Schechter CB, et al. Long-term outcomes and cost-effectiveness of breast cancer screening with digital breast tomosynthesis in the United States. J Natl Cancer Inst. 2020;112(6):582-589. doi:10.1093/jnci/djz184