There has been a lot of conversation in the news about our “breast friends” and the diagnosis and protocols for dense breasts. If you have dense breasts like me, you might be confused about the best breast imaging protocols for your preventive care.
Radiology is vital in diagnosing and monitoring medical conditions using various imaging techniques. These imaging studies aid in early detection and accurate diagnosis of diseases along with guiding treatment planning and interventions.
With a diagnosis of dense breasts, supplemental imaging might be necessary. There are various options besides mammography, such as breast ultrasound and breast MRI. Another option is molecular breast imaging.
Elizabeth Hawk, MS MD Ph.D., Interim Chief, Health Sciences Associate Clinical Professor, University of California San Diego, Division of Nuclear Medicine, Department of Radiology, and Rebecca Rakow-Penner, MD, Ph.D., Radiologist, Associate Professor of Radiology and Deputy Director for the UCSD Center for Translational Imaging and Precision Medicine.
It was fun to learn that these two doctors had been interns together. Also, they both had babies while interning (Wonder Woman has nothing on them!!!) and are girl fans of each other! It’s so cool that they now work at the same institution.
I was curious as to why they chose medicine as their career path. Dr. Hawk said she has a love for the human body. She believes that radiology strips down all the external things we judge each other by and reduces us to our commonalities underneath. She is a physician-scientist which means she does both clinical medicine and science. She chose molecular medicine because “it is the cutting edge of science.”
Dr. Rakow-Penner is also a physician-scientist. Her passion and expertise are in women’s breasts and pelvis health. She does all modalities of breast imaging, including molecular breast imaging. As she puts it, “I am an MRI fanatic.”
If you have breast imaging performed in California and are diagnosed with dense breasts, CA mandates that you automatically receive a notification. This requirement went into effect in 2013. (Thank you, California, for protecting and advancing women’s health.) Thank goodness, in March of 2023, the FDA required that all mammography facilities nationwide notify their patients if they have dense breasts. This notification will go into effect as of Sept 2024. You can read more about this in Menopause Mondays®Important Information About Dense Breasts & Breast Cancer Risk.
I was slightly insulted when I was notified that “the girls” were dense. No one wants to have dense anything. Dr. Rakow-Penner explained that dense breast tissue means that you have more fibrous and glandular tissue and less fatty tissue. I was surprised to hear that 50% of women have dense breast tissue. It was disturbing to learn that although all mammography facilities will be required to notify women if they have dense breasts, there is currently no change in the official screening recommendations. (Grrrrrrrrrrrrr!) She confirmed that reviewing images of dense breasts is a bit more challenging for radiologists, which is why they are highly trained.
Here is the USTPF’s statement on dense breast screening recommendations, “Unfortunately, there is not yet enough evidence for the Task Force to recommend for or against additional screening with breast ultrasound or MRI. We are urgently calling for more research on whether and how additional screening might help women with dense breasts find cancers earlier.” Rakow-Penner explained that dense breast tissue is usually associated with youth and a reflection of our hormonal status. As we age, our breasts become less dense and fattier. Hmmmmmmmmmmmmm, age = wisdom = more fat. I definitely have the age thing covered. I hope I have the wisdom thing covered, and I wish the fat thing covered me less!
There are four levels of dense breasts: fatty breast (almost entirely fatty), scattered fibroglandular density, heterogeneously dense, and extremely dense. In California, women receive a letter informing them if they have dense breasts and the density category.
The two flavors they focus on are:
- Heterogeneously dense: A mammogram shows many areas of fibrous and glandular tissue. According to BreastCancer.org, about 40% of women get this result.
- Extremely dense: The breasts have large amounts of fibrous and glandular tissue. About 10% of women fall into this category.
We discussed molecular breast imaging and how it differs from the current, more common breast imaging, such as mammograms, ultrasound, and MRI with or without contrast.
Molecular Breast imaging involves injecting a small amount of radioactive tracer into the bloodstream, which is then taken up by breast tissue cells. A gamma camera captures breast images, detecting areas of increased metabolic activity, which can indicate cancerous lesions.
Dr. Hawk explained that many things get lumped into one basket when discussing molecular imaging. There are several kinds of molecular breast imaging. The technique described above utilizes small semiconductor-based gamma cameras and has been used for years for a small population that cannot get an MRI. This form of molecular imaging is not used to guide biopsies. The newer type of molecular imaging is breast-specific Positron Emission Tomography (PET), also known as Positron Emission Mammography (PEM.) PEM is the promising future of breast molecular imaging.
Rakow-Penner added that PEM probably won’t be the first line of screening. She said that a mammogram is recommended as a first line of screening, and for women wanting additional screening, she recommends an MRI. MRI is still the most sensitive and preferred screening method. As she puts it, “Our role is to do no harm. A mammogram is low radiation. An MRI has no radiation as opposed to molecular imaging, which exposes a woman to more radiation.” She admits that molecular imaging plays a role in breast imaging care but is not at the screening stage with current technology.
Mammograms typically deliver about 0.4 -0.7 mSv (millisieverts) per exam. The radiation from molecular breast imaging with gamma rays is generally within the range of 1-2mSv. Dr. Hawk explained that each molecular tracer (this refers to the radioactive IV given during treatment) and piece of equipment has slightly different levels of radiation.
I asked both doctors what age women should start breast screening and when to stop.
For background, the USPSTF’s draft recommendation announced in May 2023 recommends that all women get screened for breast cancer every other year starting at age 40 -74.
Both doctors recommend getting your first mamo at 40. Dr. Hawk mentioned that she recently stepped down after ten years of service in leadership for the American College of Radiology. The ACR also has a lobbying arm called RADPAC. These groups aim to make sure the guidelines are evidence-based and what is best for the patient. They look at minimizing radiation and unnecessary exams. They want women to get the proper exam for the right reason. There is a hard recommendation from the ACR and radiologists to get breast screening at age 40. However, in contrast to the USTSPF, the ACR recommends screening be done yearly, not every other year. In addition, new ACR guidelines say all women — particularly women considered high-risk — need a breast cancer risk assessment by age 25.
As a radiologist, Dr. Rakow-Penner stands with the ACR guidelines of screening annually starting at age 40. Annual screening has an increased chance of catching cancer early.
As I approach 70 and have no intentions of stopping my breast prevention screening in 4 years as the USTPF recommends, I asked Dr. Rakow-Penner when women should stop getting mammograms. She said, “It all depends on how healthy you are. If you are healthy and vibrant and can withstand breast cancer treatment, keep screening so that you can catch issues early. Have your physician advocate for you to ensure you get the screening you need and deserve.”
Since the USTPF and the ACR recommendations differ, it is best to consult with your menopause specialist. Thanks to these fabulous doctor scientists, you are armed with the knowledge and empowered to ask the right questions. Your menopause specialist can evaluate and create preventative breast health screening protocols that fit your health needs.
Both experts encouraged us to continue asking questions, as our advocacy does not go unnoticed. Together, we can help drive more women’s health research! A great place to do this is to speak out on social media. Dr. Hawk agreed. She says that she loves the social media world as it breaks down silos and barriers so patients can ask hard questions to scientists and researchers.
As new scientific findings emerge, the guidelines for dense breast imaging may be updated. Menopause Mondays® is here to keep you up on cutting-edge science and empower you to take proactive steps to monitor your breast health.
I thanked both Drs. Hawk and Rakow-Penner for choosing to go into medicine and focusing on women’s health!
My Motto: Suffering in silence is OUT! Reaching out is IN!
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