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Monday, August 13, 2012

Attai: A vital question for all women: Are you dense?

By the time I see my breast cancer patients, many of them already know their diagnosis. All are shaken by the discovery of cancer, especially those whose cancer was found belatedly and who thought they had done everything right — regular mammograms and self-exams — to catch any cancer early.
While tumor biology often dictates the course and aggressiveness of the disease, early detection can improve the chances of survival, which is why doctors recommend regular mammograms.
Yet, as a surgeon specializing in the treatment of breast disease, I know that mammography is far from ideal. This is particularly true for women with a normal and common condition called dense breast tissue — a relatively higher concentration of glandular tissue to fatty tissue.
But while normal and common, the added risk presented by dense breast tissue is not well known among women, which is why the California Legislature declared last Wednesday "Are You Dense? Day," as was called for in a resolution authored by state Sen. Joe Simitian, D-Palo Alto.
The goal of "Are You Dense? Day" was to inform women that dense breast tissue both increases the risk of cancer and makes it harder to detect. Dense breast tissue is present in approximately 40 percent of all women undergoing mammograms. Yet, fewer than 10 percent of women are aware of their breast density.
Women who are aware of their breast density, and who talk to their physicians about it, are more likely to discover any abnormalities early in their development. Every year in this country, approximately 200,000 women will be diagnosed with breast cancer, and approximately 40,000 will die from it. A woman with dense breast tissue is four to five times more likely to develop cancer than a woman without it.
The breast is a very difficult and complex organ to image. Because both dense breast tissue and cancer and calcifications create a mammogram image that is mostly "white," looking for cancer amid dense breast tissue has been described as "trying to find a polar bear in a snowstorm."
A woman with dense breast tissue has a 50 percent to 75 percent chance that her cancer will be missed on a screening mammogram, increasing the likelihood that it will not be detected until a later stage, possibly when it is no longer potentially curable.
In many areas of medicine, patients are given a copy of test results and can ask about results they do not understand. This often does not happen with a mammogram. The federal Mammography Quality Standards Act dictates that centers that perform mammography provide a woman with a "layperson letter," which in very basic terms notes whether an abnormality is present or not. It might commonly say "your mammogram shows no evidence of cancer," along with a recommendation to return in one year.
The patient's physician receives a very different report. It will describe detailed findings, including a notation of the density of the breast tissue such as "due to the breast density, the sensitivity of mammography is limited." Many physicians inform the patient only that the mammogram was "normal." Most women with dense breast tissue do not know that their mammogram might have missed something.
To assure that women receive this information, Senate Bill 1538, introduced by Simitian, would require that the patient's mammogram report include breast density information and suggest further discussion with her doctor of the possible benefits of additional screening.
The root of the word "doctor" is from the Latin docere — "to teach." Physicians should welcome the opportunity to provide patients with information and guidance.
"Are You Dense? Day" seeks to educate women about the importance of asking about their breast density.
If they learn they have dense breast tissue, this should prompt further discussion regarding risk factors and whether additional imaging such as ultrasound or MRI might be helpful, depending on the individual situation. Even though no imaging technique is perfect, supplemental screening increases the chances of discovering cancer, and newer, more sensitive tests are continually being developed.
Only when patients are provided with full test results, placed in proper context, can they partner with their physicians to make decisions that are in their best long-term health interest. Ask your physician, "Am I dense?"
Deanna Attai, M.D., is a breast surgeon at the Center for Breast Care Inc. in Burbank. She has been in practice for 17 years and has focused exclusively on the care of patients with diseases of the breast since 2004.
© 2012 Ventura County Star. All rights reserved. This material may not be published, broadcast, rewritten or redistributed. 

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