Breast Cancer Screening Options for Women with Dense Breast Tissue

Cynthia Barone, D.O., board-certified radiologist, is the Regional Director of Breast Imaging for Monmouth Medical Center, Community Medical Center, and Monmouth Medical Center Southern Campus, RWJBarnabas Health facilities

With progress continually being made in the screening and diagnosis of breast cancer, early detection can be life-saving. While most women are aware of the importance of breast cancer screening and getting a yearly mammogram, many probably do not know about the additional screening options that are available. Mammograms continue to be the best way to be proactive about your breast health, however, they can sometimes miss tumors in women with dense breast tissue.

Breast density can be broken down into four groups: fatty (10 percent of the women), scattered fibroglandular (40 percent of women), heterogeneously dense (40 percent of the women) and extremely dense (10 percent of women). Your breasts are considered dense if you have a lot of fibroglandular tissue but not much fat. According to the American College of Radiology, “dense” breasts are categorized as both the heterogeneous and extremely dense breast – which together, makes up 50 percent of the population. Breast density is determined by the radiologist who reads your mammogram and will be included in your imaging report. In fact, under the NJ Breast Density Law, reports must include information about breast density. In New Jersey, this legislation also requires insurers to cover supplemental evaluations, such as ultrasound or MRI, in women with dense breast tissue.

Dense breast tissue can make it harder to find a cancer on a mammography. Dense breast tissue may mask a cancer on a mammogram and obscure small breast masses. Both breast tissue and cancer appears white on a mammogram, so I tell my patients that it’s like trying to find “a snowman in a snowstorm.” In fact, because of this masking effect, women with extremely dense breast tissue are at 2-6 times the risk of developing breast cancer than the average female population. As per the new breast density law, women with this category of density are eligible for additional methods of screening for breast cancer, covered by insurance. Additional screening methods available for women with dense breast tissue include breast ultrasound, 3D mammography and breast MRI.

Breast Ultrasound
One supplementary method is screening whole-breast ultrasound which is preferable for women with an average risk for developing breast cancer. Whole-breast ultrasound is done in conjunction with and does not replace mammography, which remains the main screening tool. Breast ultrasounds alone are not sufficient to screen for breast cancer because sometimes early signs of cancer, like tiny calcium deposits known as microcalcifications, don’t show up. However, this additional method can help to detect cancer that may not be seen on mammograms. A whole breast screening ultrasound can double the detection rate of breast cancer in women with dense breasts beyond what a mammogram alone can find. You are considered a candidate for whole-breast ultrasound if you have dense breasts, which would be noted in your mammogram report as either “extremely dense breasts/density score of 4” or “heterogeneously dense breasts/density score of 3”.

How are breast ultrasounds done?
A breast ultrasound is a fairly simple outpatient process and can be done one of two ways:

  • A hand-held whole-breast ultrasound: A physician or sonographer performs the ultrasound of the entire breast using a hand-held ultrasound probe called a transducer
  • An automated whole-breast ultrasound: a machine performs the examination with an ultrasound probe through an automated process. If any abnormalities are found, a hand-held ultrasound is performed to further evaluate

3D Mammography
Another available screening option for women with dense breast tissue is the three-dimensional (3D) mammography, also known as tomosynthesis. This is a type of digital mammography that produces an- image of the breast by using several low dose x-rays obtained at different angles. For tomosynthesis, the breast is positioned and compressed in the same way as for a mammogram, but the x-ray tube moves in an arc around the breast. The information is then sent to a computer, which produces a more detailed image of the breast. These images enable doctors to see inside the breast more clearly than with a standard 2-view mammogram and may help to detect signs of cancer in dense breast tissue.

Although effective for women with dense breast tissue, a 3D mammogram may not be as beneficial for women with extremely dense breasts. Whole breast ultrasound is a better option for women with extremely dense breasts because the same problem can occur in a 3D mammogram that occurs with a regular mammogram – sometimes the white cancer cannot be seen through the white breast tissue. Be sure to talk to your doctor about what supplemental screening method is best for you.

Breast MRI
Breast MRI is the best imaging modality. However, breast magnetic resonance imaging (MRI) as an additional screening method is typically reserved for high-risk patients. High risk patients are women who have an elevated lifetime risk of breast cancer. Speak with your doctor to determine if a breast MRI is right for you as a supplemental screening examination.

In recognition of Breast Cancer Awareness Month, I urge all women to be proactive about their annual mammogram screenings and staying educated on new screening methods. Whole breast ultrasound and breast MRI in addition to regular mammograms or 3D mammograms can help to improve the detection rate of breast cancer in women with dense breast tissue. If you have dense breasts, talk to your doctor. Together, you can decide which, if any, additional screening exams are right for you.

Visit Monmouth Medical Center to learn more about breast care, mammography and breast ultrasounds. Visit the Jacqueline M. Wilentz Comprehensive Breast Center in Monmouth County and Ocean County to schedule an appointment for a breast screening. 

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