While 21 American states currently have laws requiring radiologists to inform women who have dense breast tissue of their increased risk of developing breast cancer, three Harvard Medical School radiologists recently wrote an opinion article stating these laws may increase unnecessary procedures and false positives for women at low- and moderate-risk of breast cancer.
The article entitled “Breast-Density Legislation — Practical Considerations“, authored by Priscilla J. Slanetz, M.D., M.P.H., Phoebe E. Freer, M.D., and Robyn L. Birdwell, M.D., was published in The New England Journal of Medicine (NEJM), and suggests that despite its good intentions, these types of laws may be leading to negative outcomes.
It has been known for some time that density (i.e., a higher percentage of fibroglandular tissue than fatty tissue) may increase difficulties in detecting breast cancer during mammography screenings. “Given recent concerns raised by the US Preventive Services Task Force about false positives and increased patient anxiety with even routine mammography screening, widespread supplemental screening for all women with dense breast tissue without careful consideration of the risks and benefits would be unwise,” said the article’s lead author Slanetz, who is the director of breast imaging research and education at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School, in a press release.
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There have been a number of different state laws, according to mandate insurance coverage, to cover additional screening tests. However, the authors believe that it may not be necessary to recommend so much additional examination, as there are other ways of detecting breast cancer in addition to screening mammography. They believe that supplemental tools should be based on existing evidence, as mammography is currently the unique screening tool able to decrease breast cancer mortality between 15 to 30%.
“Having dense breast tissue increases a women’s lifetime risk of breast cancer, but it’s important for health care providers to place this risk in perspective for each patient,” Dr. Slanetz stated. “At present, risk stratification is likely going to help guide recommendations regarding which women might benefit from supplemental screening, regardless of their breast density. This conversation also offers an opportunity to engage women in their own health care and forge stronger patient-doctor relationships.”
Supplemental screening with breast MRI for women with high-risk of breast cancer is thought to be diagnostically effective and cost-effective, but there is no certainty about the effectiveness of ultrasonography screening for women with dense tissue, despite the fact it is mandatory by some state laws.
Moreover, the authors highlight the need to develop more effective diagnosis and treatment tools able to differentiate between clinically significant and insignificant tumors.