Gentle Reminder for the Dense Breasts Ladies

From what I've read, density can't be determined by feel.  A breast that feels thick & more solid might actually not be dense and a breast that feels soft and smooth might be dense.  I don't know if the Arimidex and lack of estrogen would have made your breasts less dense.  Possibly, but we're each indivduals so my guess is that there is no single answer to that question.  Supposedly our breasts get less dense once we hit menopause but I'm past menopause and my breast is still extremely dense.  My mother is in her mid-80s and she's been told that her breasts are still very dense.

You need to have the radiologist who views your mammograms films to tell you if your breasts are dense.  And by the way, "dense breasts", ones that are hard to read on a mammogram, are those that have 75% - 100% density, so we're talking really dense.

"Please remember that everyone who has dense breasts needs to have a MRI every other year along with a mammogram.  This will take years to get posted as the protocol for all doctors so take care of this yourself."

I would be right there in line if my surgical onco, my med onco, my cancer center, and/or my insurance company agreed with that statement; but they don’t.  Neither do the National Comprehensive Cancer Network (NCCN), the American Cancer Society, or the American Society of Clinical Oncology.  They're the groups writing the guidelines that, for the most part, determine the "standard of care" for cancer treatment and surveillance in the U.S.

At this point, the use of contrast breast MRI to screen women for BC, even if they have dense breasts, is not the standard-of-care in the U.S., except in very specific circumstances.  There is plenty of evidence that dense breast tissue makes it difficult to see abnormalities in a mammogram; and there also is evidence that dense tissue seems more prone to developing malignant tumors.  So far, though, dense breast tissue isn’t on the official list of “high risk” characteristics that justify MRI for screening.  Apparently, there’s too much disagreement about how breast density should be measured and reported.

So, the oncology groups are holding back on recommending breast MRI for women with dense breast tissue unless those women are in another high-risk category.  And, from what I’ve read, having a personal history of BC (the sporadic kind—not the inherited kind) does not put us at “high risk” for another tumor.  Our risk is increased, but not enough to put us in the category that justifies regular breast MRI’s for screening.

Here's what the 2008 NCCN Guidelines say about using breast MRI for screening:  “Current evidence does not support the routine use of breast MRI as a screening procedure, in average risk women.  Criteria for the use of breast MRI screening as an adjunct to mammography for high risk women include:  1) have a BRCA 1 or 2 mutation; 2) have a first-degree relative with a BRCA 1 or 2 mutation and are untested; 3) have a lifetime risk of breast cancer of 20-25 percent or more as defined by models that are largely dependent on family history; 4) received radiation treatment to the chest between ages 10 and 30, such as for Hodgkin’s Disease; 5) carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes.”

There’s a new section, “Principles of Dedicated Breast MRI Testing,” in the NCCN guidelines on follow-up of women who’ve been treated for BC.  That new section says:  “[Dedicated breast MRI testing] May be used for staging evaluation to define extent of cancer or presence of multifocal or multicentric cancer in the ipsilateral breast, or as screening of the contralateral breast [for] cancer at the time of initial diagnosis. … Falsely positive findings on breast MRI are common. … Utility in follow-up screening of ipsilateral and contralateral breast of women with prior breast cancer is not defined.”

In 2007, the American Cancer Society issued a report, “Guidelines for Breast Screening with MRI as an Adjunct to Mammography.”  Here are their recommendations:

“Recommended Annual MRI Screening (based on evidence):  1) BRCA mutation; 2) first-degree relative of BRCA carrier, but untested; 3) lifetime risk 20-25% or greater, as defined by BRCAPRO or other models that are largely dependent on family history;

“Recommended Annual MRI Screening (based on expert consensus opinion):  1) radiation to chest between age 10 and 30 years; 2) Li-Fraumeni syndrome and first-degree relatives; 3) Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives;

“Insufficient Evidence to Recommend for or Against MRI Screening:  1) Lifetime risk 15-20% as defined by BRCAPRO or other models that are largely dependent on family history; 2) lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH); 3) atypical ductal hyperplasia (ADH); 4) heterogeneously or extremely dense breast on mammography; 5) women with a personal history of breast cancer, including DCIS;

“Recommend Against MRI Screening (based on expert consensus opinion):  women at < 15% lifetime risk.”

The ACS guidelines do say that, especially for women at intermediate risk (i.e., 15-20% lifetime risk), “…Payment should not be a barrier.  Screening decisions should be made on a case-by-case basis, as there may be particular factors to support MRI.  More data on these groups is expected to be published soon.”

The most recent guidelines (2006) from the American Society of Clinical Oncology say this about breast MRI:  "Breast magnetic resonance imaging (MRI) is not recommended for routine breast cancer surveillance. ... Although screening breast MRI seems to be more sensitive than conventional imaging at detecting breast cancer in high-risk women, there is no evidence that breast MRI improves outcomes when used as a breast cancer surveillance tool during routine follow-up in asymptomatic patients. The decision to use breast MRI in high-risk patients should be made on an individual basis depending on the complexity of the clinical scenario."

What all this means is that many of us are going to have a tough time convincing our oncos and our insurance companies to support breast MRIs for screening purposes.  There isn’t enough evidence to justify them as “standard-of-care” yet, even if we’ve had BC and our breast tissue is dense … unless we have a hereditary form of BC.  But, the rules could change.

otter 

Beesie, you're right of course ... although somewhere I read that a personal history of BC only puts us at "moderate" risk of recurrence--not at high risk.  Since the onco groups seem to define "high risk" as above 20%, I figure we're in that next lower tier.

And, I know, ... I just KNOW, this all will change in a year or two, when the radiologists figure out a way to reproducibly measure breast density.  That really is one of the big holdups here in the U.S.  For a clinical study to show irrefutably that there's a link between breast density and BC risk, there needs to be a reliable way to measure and report breast density; and the results have to be reproducible.  Right now, it's just based on someone's eyeballed judgement of what's on the X-ray film or screen.  For one thing, it's a 2-dimensional representation of a 3-dimensional object (a breast), and there is argument about the role of breast size and thickness and stuff like that, in determining "density".

We all know how stingy insurance companies are in the U.S., and with our current economic situation, I doubt that will change much.  There might even be a stronger emphasis on the need for "evidence of effectiveness" in the future (and more denial of MRI requests).  That's because of the $1.1 billion in the recently approved "economic stimulus package" that's designated for "research to compare the effectiveness of medical treatments."  The insurance industry is thrilled with that little morsel, because everyone assumes it will allow (even mandate) denial of reimbursement for drugs and procedures that are determined to be more costly, but not significantly more effective, than others.  ("Effectiveness" can be defined several ways.)  It's presumed that the new U.S. scheme will be similar to the "NICE" guidelines used in the U.K.

<sigh>

otter 

Well this is interesting, because in our area it (MRI) is considered "standard of care" for women "at high risk" and "dense breast".. and apparently it is common for regions to do things one specific way (per medical write-ups)..  so although I only had a "high risk"my genetic counsel suggested that I get an MRI - it found DCIS that mammo's s/g and digital mammo had not seen!  (I then made the insurance company pay -- long process but it had to be done <g>).. 

I have noticed though as I follow this (MRI use for bc discussions) that I am seeing a great deal of medical write ups suggesting that MRI's be taken off the table because "women are more likely to choose bi-lateral mastectomy" if MRI's find cancer early.. I find this troublesome as we have all heard for years "get the cancer early" and now that the MRI seems to be doing that, they (medical society) seems to be suggesting that it be taken off the table.  Puzzling!

Hi Otter:  Yup and I think that doc's should look at their own confussion about what to do when DCIS is the dx..  I saw so much confussion that I decided to go for the bi-lateral BECAUSE of the docs not because of the MRI  -  Sheesh is right!

My question is...if you have dense breast, dx with bc ... do you think the doc would forgo the mammo and just do a mri? I never thought about asking to forgo the mri...just one x ray to expose my breast to...

Hi!  I would suggest that you call the centre that does the MRI's and ask them directly (the radiologists) whether MRI's can pick up the calcifications, as my MRI did mention a potential calcification that when checked was not cancer.. so I believe it might be more difficult to get because you need a well trained eye to pick it up but my understanding is that anything a mammo can pick up an MRI can as well.. There are many things floating around in both a mamo and MRI the difference is that mammo's have more people properly trained in reading them as apposed to MRI which are relatively new and so it has taken awhile for the radiologists to work with it to it's maximum potential.. 

PS as to otter's point about insurance, my doc's and insurance are now in agreement with the once a year MRI - I get it without any hickup at all... so as with most new things we have to change the insurance companies mind if we believe we need something.. That means we MIGHT have to pay out of pocket until we can get them to cooperate, but I think, at least in the US sometimes we looked to the insurance company's too much, if we are to take responsibility for our health sometimes we will have to pay out of pocket.. and with ongoing evidence it will make it easier for those in the future.. I realize that most of us are in an economic mess right now, but as far as I'm concerned if I have my health and enough to eat I'll do without other things.  Food, health and I'm a happy camper even if I'm poor (and I most certainly have been poor in my life time).  It's a major issue, insurance I mean, but sometimes we have to take the relationship with our doc and our own common sense and do what is right not what is approved...

Deirdre1 wrote "I find this troublesome as we have all heard for years "get the cancer early" and now that the MRI seems to be doing that, they (medical society) seems to be suggesting that it be taken off the table.  Puzzling!"

Such a wonderful point!!!!!! Thank you. mg