For dense breasts, doctor-patient communication is still the best policy

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For years, breast cancer awareness campaigns have urged women not to miss their scheduled mammograms. Yet there are some women for whom a regular mammogram is not enough. The latest research shows that women whose breasts are composed mostly of dense tissue can have a mammogram year after year and still have their breast cancer go undetected.

These findings on breast density have gained recognition not only in the realm of biomedical research; they re now beginning to influence legislation. Groups advocating patient awareness have been urging state legislatures to pass a bill that would make it mandatory for a patients mammography report to include breast-density information. The mandate is now a state law in Connecticut, Texas, Virginia, and as of this July New York.

But will such mandates ultimately benefit women? The answer is complicated.

Dense breasts can cloak cancers because of the way dense tissue appears on a mammogram. Dense tissue increases the chances of missing a dangerous lesion because, like cancerous tissue, dense tissue appears as a lighter shade of grey on a mammogram. This characteristic makes it more difficult to differentiate between normal tissue and cancerous lesions. JoAnn Pushkin, founder of D.E.N.S.E. (Density Education National Survivors Effort), explains that using a mammogram to try to find a tumor in a dense breast is like trying to find a snowball in the middle of a blizzard. According to a study published in JAMA, she says, breast tumors in women with dense breasts are found only 50 percent of the time that is, every other woman in this category risks going undiagnosed. Compounding this problem, according to a review published in Breast Cancer Research, women with dense breasts have an even greater risk of developing breast cancer than those who have a first-degree relative with breast cancer.

Given these facts, at first glance it s hard to see what could be problematic about legislation intended to inform women about the presence of dense breast tissue.

However, the problem that may arise with this type of legislation lies in one word: over-diagnosis. It s a phenomenon that s a concern for all women being screened for breast cancer, regardless of their breast density. A recent Norwegian study, published in the Annals of Internal Medicine, found that up to a fourth of breast cancers detected by mammograms would never have resulted in significant disease. In an editorial accompanying the study, Dr. Joann Elmore of the University of Washington School of Medicine and Dr. Suzanne Fletcher of Harvard Medical School observed that, because screening in the U.S. is initiated at a younger age than it is in Norway, over-diagnosis almost certainly occurs more often in this country.

Will a breast density notification mandate lead to a slippery slope of further tests, exacerbating the already serious problem of over-diagnosis? This question cannot be answered with a simple yes or no. On the one hand, women have the right to be aware of their current physical status and the risks that accompany it. However, the problem of over-diagnosis cannot be taken lightly. Patients and doctors must be aware that tissue density notification may go hand in hand with increased emotional stress.

Over-diagnosis is a quickly growing problem here in the U.S. Such unnecessary diagnoses cause not only anxiety and stress; they carry with them unnecessary painful medical procedures such as biopsies and surgeries.

This is not to suggest that, because there are cons as well as pros to the issue, women and their families should do nothing. However, to maximize best outcomes, perhaps mandated individual notices are not in fact the most effective route to take when it comes to breast density. That is, knowledge without an informed dialogue between patients and caregivers may not be helpful in the long run.

By improving communication between doctors, public health agencies, and the public, we can increase knowledge and awareness of the concerns associated with dense breasts. Measures such as public education campaigns, for instance, may very well be a more effective means of dealing with this fraught issue. Whereas a tissue density notification mandate would simply send patients away with a stamp of dense breast and a need for further testing, a woman who is aware of her own risk factors can have an informed discussion with her health care provider to determine a tailored course of action. The beneficial upshot would be further testing only for those with higher than average risk.

A mandate alone will have a limited benefit. The key to truly making a difference for women with dense breasts is not so different from how healthcare should be practiced across the board: informed communication between doctors and patients.