Tuesday, September 4, 2012


Nancy Cappello had annual mammograms for a decade and each time radiologists noted in their reports that she had dense breast tissue. But doctors never told Ms. Cappello, nor did they warn her that it could make her mammograms less reliable.
When her doctor found a suspicious ridge during a manual exam eight years ago, she had a mammogram and an ultrasound on the same day. The mammogram again spotted nothing amiss, but an ultrasound found a tumor the size of a quarter. Her breast cancer had also spread to 13 lymph nodes.
Ms. Cappello, then 51, was dismayed to learn that the tumor wasn't visible on a mammogram because dense breast tissue like hers can frequently hide cancer from view. "I kept asking my gynecologist, 'Why don't you routinely tell women this?' And the answer I got was, 'There is not a standardized protocol,' " she says. The industry is not on the same page.

In 2005, while still undergoing chemotherapy, radiation and surgeries, Ms. Cappello, an education administrator in Woodbury, Conn., started a campaign called "Are You Dense?" to educate other women about dense breast tissue.

Thanks in part to her efforts, last month, New York became the fourth state, after Connecticut, Texas and Virginia, to require radiologists to inform women if they have dense breasts along with their mammogram results. Similar bills are pending in 12 states and Congress. They face opposition from insurers and major medical groups concerned that the information could raise health-care costs and scare women unduly.

Studies show that having dense breasts raises the risk of developing breast cancer fourfold to sixfold. "It's a greater risk factor than having a mother or sister with the disease," but few women know this, says Deborah J. Rhodes, a preventive medicine specialist at the Mayo Clinic in Rochester, Minn. "Most of the physicians ordering these tests are also in the dark about this and the implications for women," she says.
Women's breasts are a mixture of dense tissue and fatty tissue (which is less dense), and generally become more fatty with age. Density can't be determined in a physical exam, only by imaging. An estimated 66% of premenopausal women, and 25% of postmenopausal women, have breasts that are dense enough to interfere with mammogram accuracy, according to a landmark 1996 study.
In studies of thousands of patients, Thomas Kolb, a New York radiologist who specializes in breast-cancer detection, showed that mammograms missed 60% of cancers in women with the densest breast tissue. Other studies have showed similar results.

"I, as a radiologist, have a problem telling a woman with dense breasts that her mammogram is normal when I know it could be inaccurate 60% of the time if she has cancer," says Dr. Kolb. Still, the American College of Radiology says there isn't enough evidence to recommend that women with dense breasts have alternative testing.
Jean Weigert, an executive with the Radiological Society of Connecticut, lobbied against the notification bill there on the grounds that it would increase costs and anxiety without much benefit. But once it passed, in 2009, she was impressed with its impact. Pooling data on 78,000 women in six different practices, Dr. Weigert found that about half of the women, or 8,651 patients, with dense breast tissue went on to have ultrasounds which found 28 cancers that weren't visible on mammograms. "We are definitely finding more cancers, most of them at very early stages," says Dr. Weigert
Connecticut, the first state to pass a notification bill, also requires insurers to pay for ultrasounds for women with dense breasts. According to Dr. Weigert's analysis, the additional screening for those 8,652 women cost $2.15 million, or $110,000 for each additional cancer found. Finding cancers early saves many times that amount compared with the cost of late-stage cancer treatment, she notes.
Even without legislation, some experts note that women can ask about their breast density, since radiologists routinely report that information to physicians. "If women are at all concerned, after a mammogram, they can call their doctors and say, 'Listen, do I have dense breasts? Do I need anything further?' " says Carol Lee, chair of the American College of Radiology's Breast Imaging Commission.
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