Oct. 13--In the latest debate over breast cancer screening, states are passing
laws requiring mammography centers to tell women about their breast density so
they can consider more imaging tests, such as ultrasound and MRI.
Dense breast tissue makes finding cancer on a mammogram more difficult. It may
also increase the chance of developing breast cancer.
In the four years since Connecticut passed the first breast density law, 10
states have done so. Bills are pending in 19 states, including Pennsylvania and
New Jersey, and a federal bill has been introduced.
This movement is being driven by breast cancer survivors who learned they had
dense breasts only after being diagnosed with advanced cancers missed by
mammograms. "My hope is to prevent another woman from going through my personal
tragedy -- 'normal' mammograms yet a hidden invasive cancer robbing me of the
promise of early detection," said Kathryn Thomas, 63, of Harrisburg.
Physicians, acknowledging patients' right to information, warn that experts
don't understand why most breasts have areas of dense glandular and connective
tissue, much less what to do about it.
In a statement last year, the American College of Radiology listed the "possible
harms and unintended consequences" of notification mandates: The assessment of
breast density is subjective. Dense breasts are common and experts disagree
about whether that alone warrants more imaging tests. Women may panic or feel
falsely reassured by their density report. Ultrasound and MRI screening could
add to the problems of false alarms, of detecting and treating trivial cancers.
The radiologists' group also warned that without insurance coverage, "there may
be an unfortunate disparity between women who can afford to pay and those who
The American Cancer Society, which recommends MRIs only for women at high risk
of breast cancer, is also leery. "We have a long history of laws being passed to
regulate health care where politicians are trying to be seen as being helpful,
and they've actually been harmful," said Otis Brawley, the society's chief
medical officer. "Ten states still have laws saying insurance companies must pay
for bone marrow transplants for breast cancer," although the awful regimen was
proved inferior long ago.
Mammography remains a hot-button issue, despite studies showing it has cut
breast cancer deaths, and federal regulation that has standardized screening
practices. Indeed, any woman whose mammogram appears reassuring gets a
standardized letter that points out breast X-rays miss some cancers.
One reason for the misses is that X-rays are mostly blocked by glandular and
connective tissues but can penetrate fat. Looking for a clump of cancer cells in
dense breasts is like looking for a golf ball in a snowbank.
Why some breasts are denser than others "is a very hot topic in radiology right
now," said Debra Copit, director of breast imaging at Einstein Medical Center.
"We're taught that dense tissue decreases with age, and fat replaces it. But I
did a study of over 90,000 women . . . and that's not an absolute. Whatever
you're born with kind of stays with you over time."
The American College of Radiology has a 1-to-4 density grading scale. But only
10 percent of women have extremely dense breasts, and 10 percent have fatty
breasts. The remaining 80 percent have a mixture.
Often, the grade is in the eye of the beholder -- the radiologist.
"One may call a woman dense while another does not," said University of
Pennsylvania radiologist Despina Kontos, who is researching objective ways to
The nature of some cancers also defies X-rays. Lobular cancers, which begin in
the milk-producing lobes and account for 10 percent of invasive breast cancers,
do not show up on X-rays because the malignant cells grow in lines, not piles.
Pat Halpin-Murphy, president of the Pennsylvania Breast Cancer Coalition, is a
survivor of lobular cancer who has championed Pennsylvania's bill. It has passed
in the state Senate and could go to a House vote this month.
"One, it saves lives," Halpin-Murphy said of a breast density law. "Two, it may
very well save money" by reducing the treatment needed.
Researchers say there are no studies to support such claims -- another reason
the rush to pass mandates is troubling.
In Connecticut, which requires insurance coverage for ultrasounds, a flood of
ultrasound exams led to detection of three additional breast cancers for every
1,000 women screened, studies found. But the ultrasounds also led to a flood of
false alarms and biopsies that found no cancers -- far more than with
mammography. "I see laws trying to fix something that is not fixable," said
Brawley of the cancer society.
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