Dec 2, 2021 04:35PM beesie.is.out-of-office wrote:

Breast density is really poorly explained by doctors and even by most websites about breast density.

Category C density is actually quite normal for your age. And as you can see from this graph, breast density tends to decline with age. Of greatest concern are those who continue to have Category D density post-menopausally. This is why MRIs are only routinely done on those with the highest level of density - otherwise, MRIs would be necessary for 50% of all women.

The other thing to understand is that when you see risk figures related to breast density, usually the increase in risk quoted is a comparison between those with the lowest density vs. those with the highest density. The two middle categories are more normal and are pretty much baked into the "average" risk figures. Therefore while risk may be somewhat increased for those with heterogeneously dense breasts, the increase against average risk would not be that great.

Having said that, with your history of breast cancer and your Cat. C breast density, a reasonable request would be to supplement your mammogram with an ultrasound. That is usually the approach taken when MRIs are not available.

Dec 2, 2021 05:07PM macdebbie wrote:

Beesie - thanks for weighing in. I did read that Category C dense breasts are quite common, but it is the combination of having dense breasts and having had cancer that is weighing on my and looking at the sensitivity rates - mammogram alone - 31-33%, MRI alone 87-96%, and mammogram and ultrasound 44-48%.

The ACR recommendations are for either breast density category of C or D to include an annual MRI if the patient has a personal history of breast cancer. The American Cancer Society recommends MRI screening in "high risk" women regardless of breast density. I would assume having had breast cancer puts me in the "high risk" category?

At the very least I would like an ultrasound as supplement to my mammograms. However, I don't understand the reluctance of doctors to prescribe and MRI when it could save lives and when it is warranted. I am not just a woman with dense breasts. They always cite "cost" but why are docs so concerned with cost. They aren't paying for it, I am, or in this case my insurance is. So why do they care? I can only guess there must be some disincentive to order MRIs or some tie with the insurance companies, but I feel like they should care about me more than they care about the insurance companies.

Unfortunately my breast density has not improved. I am 64 now and my breasts are just as dense as they were in my 40s and 50s.

Salamandra - Thx for your thoughts. It's very hard for me to get a second opinion from a prestigious cancer center. Unfortunately Telehealth visits are disallowed and I don't want to be traveling with COVID. The best I could do is go to the other hospital group for a consult with another breast surgeon. That hospital is a teaching hospital and is nationally ranked in Cancer. Certainly not on the level of a Dana Farber which I would have gone to back home, or a Johns Hopkins though.

The breast surgeon I went to is considered the best in this area, probably the entire state. I felt very comfortable with her and her level of expertise but I do not agree with her here. I'd much prefer to be cautious. And if I have to go through a few false positive biopsies so be it. Better than getting cancer again.

I have heard of the "please make a note in my file" play, and if push comes to shove I will use it, but I don't want to create tension in this relationship as she is who I would want to go to if I need breast surgery ever again, God forbid.

Dec 2, 2021 06:04PM Carlsoda wrote:

Hi macdebbie, I am sorry you are going through this. But I am glad you are asking questions. I also have dense breasts and I’ve had breast cancer in the same breast twice now and the 3D mammo didn’t catch it either time. Because of this we will be doing both 3D mammo and a MRI 6 months apart moving forward. I would hope your MO would be willing to do this for you too. So keep fighting for it!

Dec 2, 2021 08:22PM bcincolorado wrote:

I have very dense tissues and the breast center where I do my mamos actually after the 3D mamo said I needed it and did it automatically. No doctor had to request other than the radiologist who read it said I needed it. They do read it when I am there and report before I leave because of my history. They do it with all the people who come in for testing there. It is affiliated with a local university hospital system though and that might make a difference as well. Best wishes.

Dec 2, 2021 09:27PM beesie.is.out-of-office wrote:

macdebbie, I do understand that your concern is the combination of having a personal history of breast cancer + dense breasts. I was simply trying to provide some more information about your level of breast density, which is average for your age. With Cat 3 density, I think your higher risk comes from having been previously diagnosed - and I personally believe that alone should get you supplemental screening. I think all women previously diagnosed, who have not have had a BMX, should be considered "high risk" and receive high risk screening. Unfortunately that's not how it generally works out, however.

What is your source for this data? "looking at the sensitivity rates - mammogram alone - 31-33%, MRI alone 87-96%, and mammogram and ultrasound 44-48%."

There may be one or two studies with those results, but the studies and meta-analyses I've looked at suggest that for women with dense breasts, mammograms alone have sensitivity of ~45%-65%, versus about 80%-90% for the combination of mammograms and ultrasounds.

"The researchers found that adding ultrasound to mammography increased cancer detection by an absolute rate of 29% -- rising from 53% with mammography alone to 82% with both screenings." RSNA: Ultrasound, MRI Helpful Aids for Dense Breasts https://www.medpagetoday.com/meetingcoverage/rsna/17318

"Overall, the sensitivity of mammography for the detection of breast cancer is 85%; however, in women with dense breast tissue, the sensitivity of mammography is reduced to 47.8–64.4." The Role of Ultrasound in Screening Dense Breasts—A Review of the Literature and Practical Solutions for Implementation https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5872003/

I recall seeing a study a while back that compared the efficacy of adding an MRI to a mammogram versus adding an ultrasound to a mammogram. As I recall, adding the MRI did increase the cancer detection rate, although the difference was surprisingly small and the rate of false positives was higher. I will dig around to see if I can find that study.