Wendie Berg, MD, PhD, discusses new breast density guidelines

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Wendie Berg, MD, PhD, Professor of Radiology, University of Pittsburgh School of Medicine, Chief Scientific Advisor DenseBreast-info.org, provided insight on the new National Breast Density Reporting Standard in a recent interview with Contemporary OB/GYN®. Find out what this means for your practice and your patients below.

Contemporary OB/GYN®: Can you briefly summarize the new National Breast Density Reporting Standard and what this means for physicians?

Wendie Berg, MD, PhD: As of September 10, 2024, all mammogram results will tell the patient if her breasts are dense or not dense. The results will include the information that dense tissue makes it harder to find cancer on a mammogram and also raises the risk of developing breast cancer. In patients with dense breasts, the results will also suggest that “other imaging tests, in addition to a mammogram, may help find cancers. ”It is important for women and their health care providers to know that dense tissue is normal and is seen in about 40% of women. But about 40% of breast cancers will go unseen on a mammogram when the tissue is dense.

There are actually 4 categories of breast density, and this detail is in the mammogram report sent to the patient’s health care provider. Fatty and scattered fibroglandular density categories are “not dense”. Heterogeneously dense and extremely dense are “dense”. The risk of cancer being hidden and also the risk of cancer developing increase with increasing breast density category.

Contemporary OB/GYN®: With the implementation of the National Breast Density Reporting Standard, how do you foresee this affecting your conversations with patients, particularly those learning for the first time that they have dense breasts?

Berg: This information may be a little confusing at first for patients, but it should be seen as empowering. Women will now have important information about the screening and risk implications of dense breast tissue, and this can inform their discussions with health providers about what screening options are best for them. Health care providers should be prepared to either be a resource of information or recommend one.

Contemporary OB/GYN®: From your perspective as a physician, how does this legislation enhance your ability to provide personalized care to patients with dense breasts?

Berg: I practice in Pennsylvania and, courtesy of the work of the Pennsylvania Breast Cancer Coalition, since 2014 a state law has required that we inform women of their specific category of breast density, as well as the risk and masking implications. Importantly, additional insurance laws have since been passed in PA (and in 30 states plus DC altogether) that require insurance coverage for additional screening with MRI or ultrasound for most women with dense breasts. This legislation will further increase patient and provider awareness.

Contemporary OB/GYN®: DBI has launched educational tools like "Is My Mammogram Enough?" and "Screening Tests After a Mammogram." How can physicians incorporate these resources into their practice to help patients better understand their breast density and associated risks?

Berg: Both patient educational tools can be linked to, shared with patients, or viewed in-office. Is My Mammogram Enough details risk factors to consider and screening recommendations based on them. Screening Tests After a Mammogram features a table showing the cancer detection of screening modalities in dense breasts. Additional tools like the Patient Fact Sheet and Patient Brochure are free to download (and available in other languages).

As detailed in the Who Needs More Screening flowchart for providers, an MRI is recommended in addition to an annual mammogram in women who are at high risk for breast cancer. The current USPSTF and ACOG guidelines do not address women at higher than average risk. Providers should be aware that women who have dense breasts are at higher risk, and if they also have a family history of breast cancer, or personal history of breast cancer or atypical breast biopsy, then they should consider having an MRI every year as adding an MRI more than doubles detection of early breast cancer compared to even a 3D mammogram alone. Not all women can tolerate an MRI because of claustrophobia, in which case ultrasound can be considered, but it is not as good. Women and their doctors should be able to discuss risk factors and options for additional screening.

More and more women are going to be asking their radiologists and their doctors for information about screening options after a mammogram. As mentioned, the Screening Tests After a Mammogram table details the number of cancers we expect to find with each test in women with dense breasts. When we screen 1000 women with a mammogram, about 5 will be found to have cancer. 3D mammograms (tomosynthesis) are a little bit better, at 6 per 1000, but cancers are often still missed in dense breast tissue. If we add ultrasound, another 1-2 women of 1000 will be found to have cancer, but about another 4% to 7% of women will be called back for additional testing for findings that are not cancer. If we add MRI, another 13 women of 1000 will be found to have cancer the first year after a normal mammogram, with additional testing needed for about 10% of women who do not have cancer. After that “baseline” MRI, each year thereafter another 3 women per 1000 will be found to have cancer only the MRI after a normal mammogram, and additional testing will be needed for about 3% of women who do not have cancer.

To help physicians prepare for conversations about supplemental screening using current guidelines, please see this article. Also available for health providers is an educational video series on breast density and supplemental screening.

Contemporary OB/GYN®: Given the current inconsistencies in state insurance laws, how might the proposed Find it Early Act help ensure broader access to supplemental breast imaging for women with dense breasts? How do you currently navigate these inconsistencies with your patients?

Berg: Currently, 33 states plus Washington DC have some form of insurance law requiring coverage for additional imaging after a screening mammogram, including 30 with laws requiring coverage for screening MRI or ultrasound. The laws vary in coverage and some state laws exclude copays or deductibles. Unfortunately, many patients have insurance plans that are not subject to state law. This includes self-funded plans, out-of-state plans, and federal plans (Medicare, VHA, and TRICARE). At present, women need to check with their insurance before having any additional screening, and a prescription is needed from their health care provider. The Find It Early Act would provide a uniform national insurance coverage standard for no-cost screening and diagnostic imaging for women at increased risk or with dense breasts. Importantly, the Find It Early Act would be updated in accordance with guidelines from the National Comprehensive Cancer Network and the American College of Radiology.