Dr. Kristin Robinson, a Mayo Clinic breast radiologist, says women with dense breast tissue are at a slightly increased risk of developing breast cancer compared to women without, and that’s why early detection is so important.

"About 50% of women have dense breast tissue," says Dr. Robinson.

Mayo Clinic Minute: What does a diagnosis of dense breasts mean?

Journalists: Broadcast-quality video (01:04) is in the downloads at the end of this post. Please courtesy: "Mayo Clinic News Network." Read the script.

Dr. Robinson says you can't tell by looking at a woman whether she has dense breasts. She says people with dense breasts have less fat and more glandular and connective tissue in their breasts.

"When we see a woman's mammogram, that dense tissue, that fibroglandular tissue, looks white, whereas the fat looks dark or like a black color. So, when we're looking at a mammogram, the more white tissue we see, the more dense a woman’s breasts are considered," says Dr. Robinson.

She says it's difficult to detect cancer in dense breasts because breast cancer and dense tissue appear white on a mammogram.

"Our sensitivity or our ability to detect breast cancer goes down in women who have dense breast tissue for that reason," she explains.

Dense breast tissue supplemental screenings

The radiologist encourages women with dense breast tissue to have supplemental screenings.

"Whole-breast screening ultrasound, MRI, molecular breast imaging, and contrast-enhanced mammography" are some options patients might consider, says Dr. Robinson.

Mayo Clinic healthcare professionals recommend annual mammograms starting at age 40 for most women. In addition, a personalized breast cancer risk assessment is suggested at age 30 for all women to see if screening is needed before age 40.

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DEAR MAYO CLINIC: I recently had my annual screening mammogram and was told everything was normal. However, I just read an article that said health care professionals must inform patients if they have dense breasts. My clinician did not share anything. Why is this information important? How do I know if I have dense breasts? What additional screening is required?

ANSWER: Breasts come in all shapes and sizes. Breast density is not determined by how a breast looks or feels. Breast density refers to the amount of fibroglandular tissue in a woman's breast compared to fatty tissue.

Fibrous connective tissue gives the breast shape, and glandular tissue responds to hormonal influences, produces milk and is where breast cancer forms at the cellular level. Fat in the breast is, well, just fat. On a mammogram, the fibroglandular tissue looks white, while the fat looks black. The whiter the breast appears on a mammogram, the denser it is considered.

Dense breast tissue by itself does not need to cause alarm. Approximately 40% to 50% of women have dense tissue. But women with dense breast tissue are at a higher risk for breast cancer compared to women without dense breasts. In addition, dense tissue can mask abnormalities on the mammogram, making it harder to detect small cancers.

Generally speaking, mammograms can detect approximately 80% of breast cancers in women without dense tissue, but that number decreases to below 60% in women with dense breast tissue. The more dense the breast tissue appears on a mammogram, the further the detection rate falls. That is one of the reasons for the most recent ruling by the Food and Drug Administration that aims to help further standardize information that health care organizations share. In 2009, Connecticut enacted the first breast density reporting law requiring facilities performing screening mammograms to inform patients about breast density, and this more recent ruling will standardize reporting at the federal level.

Mayo Clinic has been providing women with information about breast density for years.

Data show us that mammograms consistently reduce breast cancer mortality by detecting breast cancer at smaller sizes and earlier stages compared to women who do not have mammograms, regardless of breast density. Mammograms still detect microcalcifications and areas of abnormal tissue that might indicate cancer is hiding. But women who have dense breast tissue should discuss the option of supplemental screening in addition to undergoing a yearly mammogram.

Breast density is only one factor that contributes to someone's overall risk of developing breast cancer. The decision to undergo additional imaging may depend on your age, exactly how dense your tissue is, your personal preferences and whether you have additional risk factors for breast cancer, including family history of breast cancer or ovarian cancer, prior breast biopsies, or exposure to hormones.

Today, there are several options for breast imaging that may be used in conjunction with the mammogram for women with dense breast tissue, including:

1. Tomosynthesis, or a 3D mammogram
   This is performed at the same time as the traditional 2D mammogram. Tomosynthesis only increases cancer detection slightly, but it does reduce the likelihood of false positive findings. This translates to a lower recall rate — getting the dreaded phone call to return for an additional imaging.
2. Whole breast ultrasound
   This technique has been used historically for women with dense tissue, although the added cancer detection rate is relatively low compared to using mammography alone. The major downside is that whole breast ultrasound has a fairly high false positive rate.
3. Contrast-enhanced digital mammography
   This can be done at the same time as the traditional screening mammogram, but uses an iodine-based contrast, delivered through an IV prior to the test. This is a newer imaging strategy, but initial research studies have been very promising.
4. Molecular breast imaging (MBI)
   MBI is a test that uses a radioactive tracer and a special camera that looks at the energy level of cells. Cells that are growing quickly take up more of the tracer than do slowly growing cells. Cancer cells often grow quickly, so the idea is that they will take up more of the tracer. MBI is a great option for women with dense tissue who do not have a lot of other risk factors for breast cancer.
5. MRI
   This test has the highest cancer detection rate, finding significantly more cancers than mammograms alone. MRI is the costliest test to image breast tissue, and current guidelines recommend MRI only for women at the highest risk for breast cancer — women whose lifetime risk exceeds 20% to 25% based on several factors. MRI also is beneficial for women previously diagnosed with breast cancer and who have dense breast tissue, or if diagnosis occurred before age 50.

The decision to pursue any of these options should be made based on several factors, including which tests are accessible in your area, your insurance coverage, the pros and cons of each test, and your individual cancer risk.

Your primary care clinician is a good person to have conversations with, but you also can ask for a referral to a breast health specialist who can help guide you further to ensure you have the most appropriate imaging based on your breast density and overall cancer risk. — Dr. Lauren Cornell, Hematology/Oncology, and Dr. Kristin Robinson, Radiology-Diagnostic, Mayo Clinic, Jacksonville, Florida

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Related Articles 

• Mayo Clinic Minute: Determining if you have dense breasts published 10/13/22
• News Release: Mayo Clinic expert offers guidance on supplemental screening for women with dense breast tissue published 10/19/21

The post Mayo Clinic Q and A: Breast density reporting and supplemental testing appeared first on Mayo Clinic News Network.

DEAR MAYO CLINIC: I am 40 and went for my first mammogram. I was told I have dense breast tissue and should have a molecular breast imaging study. What does it mean to have dense breasts? Am I at increased risk for breast cancer? What is this additional test, and will it replace mammography in the future?

ANSWER: For years, a mammogram has been the standard test for most women to evaluate their breasts for potential areas of concern. Mammography is not going away and remains the first line of defense for detecting breast cancer. Rather, new technology has been introduced for women who might need more enhanced imaging in addition to a mammogram, which is often referred to as supplemental screening.

Breast density refers to the relative proportion of fatty tissue versus glandular or fibrous tissue when viewed on a mammogram. The tissues look different on a mammogram. Specifically, fat appears black on a mammogram, while milk glands and fibrous tissue of the breast appear white. The more white tissue that is seen on a mammogram, the more dense a breast is considered. You cannot see or feel the difference yourself.

Dense breast tissue is relatively common and is found in approximately half of women. The presence of dense breast tissue can make it more difficult to detect abnormalities in the breast since both the tissue and cancer appear white on a mammogram, potentially masking cancer. Statistics also indicate that women with dense breasts are four to six times more likely to develop breast cancer than women without dense tissue. Therefore, these women may benefit from supplemental screening.

Mayo Clinic developed a test called molecular breast imaging, or MBI, which looks at the function of the breast tissue rather than the anatomy. Molecular breast imaging is more accurate in distinguishing tumors from normal tissue.

With this imaging, tumors stand out from the background tissue. Several studies showed that molecular breast imaging consistently finds about three times more breast cancers in women who have dense breast tissue than screening mammography alone. These findings indicate that molecular breast imaging is an important tool for early breast cancer detection in certain women.

One in 8 women is going to get breast cancer in her lifetime, and the goal is to find those cancers while they are small and most treatable. Molecular breast imaging is one tool that helps do that.

In a molecular breast imaging exam, a woman receives an injection of a radiotracer, which is a radioactive agent that goes to active parts of the breast and lights up in areas that have more metabolic activity, like cancer. The breasts are placed in mild compression to stabilize them while pictures are taken. The compression used is less than what occurs with a mammogram, and most women report that it is not uncomfortable. Imaging takes about 40 minutes, and patients can watch a show or play a game on their phone while the pictures are taken.

The radiotracer used in molecular breast imaging has been used for other medical imaging tests for decades, and it is safe. The radiation doses for mammography and molecular breast imaging are low — below the amount of background radiation a person will get in any given year just by walking around outside. Detecting breast cancer early saves lives and outweighs any theoretical risk from the extremely low doses of radiation incurred by these exams.

Speak with a breast health specialist to understand your specific risk for breast cancer. This can help you gauge whether additional imaging is right for you. At the very least, all women should get a yearly screening mammogram. However, women with dense breast tissue should consider supplemental screening. Molecular breast imaging is an important complementary tool that helps find cancers that might otherwise go undetected for a long period of time because they are masked on a mammogram. — Dr. Kristin Robinson, Division of Breast Imaging, Mayo Clinic, Jacksonville, Florida

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Related Article

• News Release: Mayo Clinic expert offers guidance on supplemental screening for women with dense breast tissue published 10/19/21

The post Mayo Clinic Q and A: Who needs molecular breast imaging? appeared first on Mayo Clinic News Network.

PHOENIX — An article published in the October issue of Mayo Clinic Proceedings offers recommendations for clinicians and patients regarding supplemental screening for women with dense breast tissue. 

Breast cancer is the second most common cause of cancer death in women. Although 1 in 8 women will be affected by breast cancer, early detection leads to improved survival.

"One challenge for some women is dense breast tissue," says author Suneela Vegunta, M.D., a women's health specialist at Mayo Clinic. Dr. Vegunta says there are millions of women in the U.S. with dense breast tissue. It's found in nearly half of women eligible for breast cancer screening, particularly in younger women. She says breast density may decrease after menopause.

Watch: Dr. Vegunta discusses supplemental cancer screening for women with dense breasts.

"Dense breast tissue is an independent risk factor for breast cancer and may also mask small breast cancers, thereby reducing the sensitivity of a screening mammogram," says Dr. Vegunta.

She says that since legislation requiring providers to notify women about breast density was passed in several states, more women are aware of their breast density and are reaching out to health care professionals with questions.

"Supplemental breast cancer screening modalities can help diagnose additional cancers that are possibly masked by dense breast tissue on mammograms," says Dr. Vegunta. "Our paper provides information and guidance for health care professionals and patients on the benefits and drawbacks of various supplemental screening modalities in the background of using a risk-based stratification of patients with dense breast tissue."

Dr. Vegunta says that dense breast tissue is only one risk factor for breast cancer. If a patient has additional risk factors, such as family history of breast cancer, experienced early menstruation, has not given birth to a child, or has a prior history of abnormal breast biopsies, she should discuss enhanced surveillance with her health care provider. 

Dr. Vegunta says consensus-based guidelines are not available related to screening women with dense breast tissue. Also, randomized controlled studies have not been performed that review the effect of supplemental screening versus mammography alone on breast cancer mortality. She says these studies, along with guidelines for screening women with dense breast tissue, are needed.

Learn more: Mayo Clinic Minute: Determining if you have dense breasts

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About Mayo Clinic
Mayo Clinic is a nonprofit organization committed to innovation in clinical practice, education and research, and providing compassion, expertise and answers to everyone who needs healing. Visit the Mayo Clinic News Network for additional Mayo Clinic news. For information on COVID-19, including Mayo Clinic's Coronavirus Map tracking tool, which has 14-day forecasting on COVID-19 trends, visit the Mayo Clinic COVID-19 Resource Center.

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• Joe Dangor, Mayo Clinic Public Affairs, newsbureau@mayo.edu

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DEAR MAYO CLINIC: After a recent mammogram, I was told that I have dense breast tissue. What does that mean? Should I be concerned? What does that mean for my future screenings?

ANSWER: When health care providers say "breast density" or "dense breasts," they are referring to how the breasts look on a mammogram. Women have different amounts of tissue and different types of tissue in their breasts.

Breasts are composed of fat, connective tissue that holds the breasts together, and the part of the breast that makes milk when breastfeeding. Those tissues look different on a mammogram. We can see through the fat, which appears black on a mammogram. However, the other types of tissue are white and can be difficult to see through. Dense breast tissue can make it more challenging to see cancer on a mammogram because the dense tissue and the cancer are both white. Dense breasts are common, with about half of women having dense breasts.

In addition to cancers being more difficult to see in dense breast tissue, having dense breast tissue confers a slightly higher risk of developing breast cancer.

Because of these issues, Mayo Clinic developed a test called molecular breast imaging, or MBI, which looks at the function of the breast tissue rather than the anatomy. We have performed several large screening trials and incorporated MBI into Mayo's clinical practice. Molecular breast imaging consistently finds about three to four times more breast cancers in women who have dense breast tissue than screening mammography alone.

Molecular breast imaging and mammography have only been studied where MBI is performed in addition to mammography. There are a couple of reasons for this.

Mammography is really good at detecting calcifications, which you can think of as tiny stones or grains of sand in the breast. Calcifications sometimes can be the earliest sign of breast cancer. Molecular breast imaging does not perform as well with abnormalities that present as calcifications only. However, MBI is very good at finding those lesions that might be hiding in the dense breast tissue, so they really work in concert together.

Molecular breast imaging uses a radiotracer, which is a radioactive agent that goes to active parts of the breast and lights up in areas that have more metabolic activity, like cancer. That activity is detected with a special camera. The radiotracer used in MBI has been used for a long time, and it is safe. The radiation doses for mammography and molecular breast imaging are very low ― below the amount of background radiation we get just by walking around outside. Any risk from radiation at these extraordinarily low doses is purely theoretical. In contrast, it is known that the risk of breast cancer is real for women. One in 8 women is going to get breast cancer in her lifetime, and the goal is to find those cancers while they are small and most treatable. MBI is one tool that helps do that.

In a molecular breast imaging exam, a woman receives an injection of the radiotracer. The breasts are placed in mild compression to stabilize them while pictures are taken, but it's less compression than a mammogram and most women report that it is not uncomfortable. Imaging takes about 40 minutes, and patients can watch a show or play a game on their phone while the pictures are taken. Women should get their yearly screening mammograms, and those women with dense breast tissue should consider supplemental screening. Molecular breast imaging is an important complementary tool that helps find cancers that might otherwise go undetected for a long period of time because they can't be seen on a mammogram. — Dr. Katie Hunt, Division of Breast Imaging, Mayo Clinic, Rochester, Minnesota

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Related Articles 

• Mayo Clinic Minute: What is molecular breast imaging and who needs it? published 10/14/19
• Mayo Clinic Minute: What women need to know about mammograms published 6/19/19

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Watch: The Mayo Clinic Minute

Journalists: Broadcast-quality video (0:59) is in the downloads at the end of this post. Please "Courtesy: Mayo Clinic News Network." Read the script.

"MBI is a relatively new tool for imaging the breast that was designed to overcome the limitations of mammography for imaging the dense breast," says Dr. Rhodes.

You see, dense breast tissue and cancer both appear white on a mammogram.

"So this tool images the breast in such a way that the tumors stand out from the background tissue and are not obscured by overlying breast density," says Dr. Rhodes.

Two large studies showed that MBI detected three to four times more cancers than mammography in women with dense tissue.

How do you know if you have dense breasts?

"Lots of women will say to me: 'Oh, I have dense breasts. I can tell by the way they feel because they're lumpy.' But that actually does not correlate with the density of the tissue. Dense tissue is defined solely by the mammographic appearance of the breast. The more white tissue on the mammogram, the denser the breast," says Dr. Rhodes.

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Dense breast tissue and breast cancer risk
Dense breast tissue refers to the appearance of breast tissue on a mammogram. It's a normal and common finding. However, health care providers know dense breast tissue increases the risk of breast cancer and makes breast cancer screening more difficult. Here's what you need to know.

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DEAR MAYO CLINIC: Every year when I get my mammogram, the results are that the breasts are too dense to see small cancers. Why should I keep getting mammograms? Should I instead ask for an ultrasound to look for cancer? Also, are self-exams still recommended? You don’t hear much about them anymore.

ANSWER: Increased breast density can make interpreting mammograms difficult. Even if your breasts are dense, however, Mayo Clinic recommends an annual mammogram starting at age 40. Some women who are at a high risk for breast cancer may need to start screening earlier. Depending on your situation, your doctor may recommend additional screening tests, too. Breast self-exams are no longer formally recommended, but it is important for you to be familiar with your breasts’ typical appearance.

Breast tissue that is not dense contains fat and appears dark on a mammogram. Dense breast tissue is composed of milk glands, milk ducts and supportive breast tissue. Dense tissue appears white on a mammogram. There are four levels of breast density: fatty, scattered fibroglandular, heterogeneously dense and extremely dense. If you have heterogeneously or extremely dense breasts your breasts are considered “dense.” Some states require the level of breast density to be documented on your mammogram report.

Because both dense tissue and cancer appear white on mammogram images, a high level of breast density can obscure cancer on a mammogram. Mammograms, however, are still very useful for detecting breast changes that could indicate cancer, even in women who have dense breast tissue. Mammograms remain one of the most important tools in the fight against breast cancer. Studies of women in their 40s and 50s have shown that screening mammograms decrease breast cancer deaths by 15 to 20 percent.

Along with your annual mammogram, talk with your doctor about your individual breast cancer risk. Women with dense breasts may benefit from supplemental imaging, such as 3D digital breast tomosynthesis or molecular breast imaging. Women with a high risk for breast cancer may benefit from breast MRI.

Be mindful that there is a downside to some supplemental screening tests. The test could find an abnormality that requires further investigation which ultimately turns out benign, therefore subjecting you to the risk of an unnecessary medical procedure. Also, your insurance may not cover the cost of some supplemental screening studies, leaving you with an out-of-pocket expense. And finally, at this time research remains inconclusive about whether supplemental breast imaging reduces the rate of breast cancer deaths overall.

Some health care facilities do use handheld ultrasound testing to scan the whole breast. However, consistent, high-quality handheld ultrasound examinations of the entire breast are difficult to perform. Mayo Clinic does not use ultrasound as a supplemental screening tool to scan the entire breast for cancer. Mayo Clinic does use diagnostic ultrasound to investigate specific areas of the breast that look or feel abnormal or appear abnormal on a mammogram image.

In addition to screening exams, breast self-awareness can be key to catching breast cancer early. The breast self-exams that used to be routinely recommended are no longer used as part of breast cancer screening. That’s because research hasn’t shown a clear benefit. Still, you should be aware of the general appearance and feel of your breasts.

If you notice any of the following changes, report them to your doctor right away: a breast lump; a change in the texture of your breast tissue; breast skin changes, such as dimpling or redness; a change in the position of a nipple; change in breast symmetry; or discharge from a nipple.

For the best breast care, talk with your doctor about your cancer screening options. Together, you and your doctor can decide based on your individual risk factors what specific breast cancer screening tests are right for you. — Dawn Mussallem, D.O., Diagnostic Breast Specialist at The Robert and Monica Jacoby Center for Breast Health, Hematology/Oncology, Mayo Clinic, Jacksonville, Fla.

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It's well known that women with dense breast tissue are less likely to get accurate results from mammograms. Now there's a new breast-imaging technology called Molecular breast imaging, or MBI, that shows promise for increasing the rate of detection of invasive breast cancers in women with dense breasts. On the next Mayo Clinic Radio, Dr. Deborah Rhodes, Dr. Michael O'Connor and Dr. Katie Jones discuss MBI. Also on the program, nurses Margo Kroshus and Sherry Rengstorf share their advice and insights about hospice care. And cardiologist Dr. Bruce Fye talks about his new book, Caring for the Heart: Mayo Clinic and the Rise of Specialization.

Myth or Matter-of-Fact: The Molecular Breast Imaging technology got its start in a garage.

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