Is the California breast density law a good idea? Three opinions
You would think there could be no downside to California’s new law that requires doctors to inform women if a mammogram reveals they have dense breasts.
But some doctors do have concerns about the legislation, which also requires physicians to tell patients that dense breasts are linked to a higher risk of breast cancer, that they make mammograms harder to read and that there are alternative breast cancer screening options.
Here are the thoughts of three doctors with whom we spoke. (Also see our blog item on this topic from yesterday.)
Dr. Otis Brawley, chief medical and scientific officer of the American Cancer Society and a professor of medicine and epidemiology at Emory University in Atlanta:
“I am concerned when people try to legislate the practice of medicine,” Brawley said. And he has other problems with this law. One is the fact that breast density scores are not yet precise: “One radiologist’s eyes may be very different from another radiologist’s eyes at this point,” he says.
But the biggest problem, he adds, “is if I have a patient with dense breasts, I am not sure at this juncture what is the right thing to do with that woman.”
Brawley believes that doctors should be frank with their patients. But he thinks the legislation is likely to result in increased numbers of women being referred for additional tests, and this may not necessarily be helpful. “More screening is more radiation, which is actually for sure going to cause more cancer,” he says, “and it’s for sure going to cause more women to have false positives and get fed up with screening and say, ‘No more screening for me.’” He says there already is a problem with women in their 40s having false positives and swearing off screening so that by the time they reach their 50s, when breast cancer screening is more important, some are avoiding the tests.
Brawley adds that some data suggest that the types of breast cancer that women with dense breasts get may be less dangerous. This may sound odd, but scientists now know that that not all breast cancer is the same and that maybe 15%-20% of the breast tumors women get are localized ones that are not going to progress, he says.
“All of these things basically create a situation where we do not know exactly the right thing to do,” he said. “And whenever we don’t know what the right thing to do is, it frightens me when you legislate what people should do.”
Dr. Maureen Chung, breast surgical oncologist and medical director of the Margie Petersen Breast Center at St. John’s Health Center in Santa Monica:
“I think the intentions are good,” Chung says of the law. But she and others she knows in the physician community have concerns that mirror those of Brawley: nonstandard breast density scores, physicians’ own uncertainties about what to do next and a probable uptick in testing procedures.
Chung says that women with dense breasts should choose digital mammography over standard, film mammography -- because studies have shown that for women younger than 50 and women with dense breasts, the images are clearer and cancers more apt to be spotted.
In considering screening options beyond mammograms that are available for those with dense breasts, women should understand something about their pros and cons, Chung adds.
Ultrasound images of the breast will be clear even when a patient’s breasts are dense. “But the quality of the ultrasound depends a lot on who is doing it, so you want to make sure you’re going to a place that has a lot of experience doing breast ultrasound,” Chung says. The downside of ultrasound is it detects a lot of things that don’t turn out to be breast cancer -- false positives -- leading to needless biopsies and anxiety for a lot of women.
Breast tomosynthesis is a more advanced kind of mammogram in which images of the breast are taken from a variety of angles to build a clearer, 3-D image. “The drawback is more radiation,” Chung says. “That’s something you have to understand -- there are risks and benefits from each test.”
Breast MRIs are the most sensitive. “You also have a lot more false positives,” Chung said. “You also are getting contrast -- you have to get an injection and you might be allergic to the contrast. It also costs a lot more.”
Again, although she thinks the intention of the law are good and that women should know if they have dense breasts, “I just think there should have been more discussion before it came through,” she says. ”We should have had standardized definitions of what a dense breast is,” as well as more time for the medical community to figure out management plans.
“I think what’s going to happen is that when women are told they have dense breasts it will increase their anxiety because they’ll think they have a huge risk of developing breast cancer. They will be sent off for repeat ultrasounds, not realizing that some ultrasounds will be of better quality than others. And I think we are going to end up with more biopsies.”
Dr. Richard Reitherman, medical director of breast imaging at MemorialCare Breast Center at Orange Coast Memorial Medical Center in Fountain Valley:
“I think it is a good idea,” Reitherman says of the law. “Physicians for years have received ... breast density information. “ And patients, in turn, have for years received a letter informing them of their mammogram result: Either it’s negative or they are asked to come back for more investigation. Now patients will get breast density information as well, he says.
“The implementation is the big deal here,” he adds. He knows that many of his colleagues are worried about patient confusion and questions about the best way to care for women with dense breasts and whether there are enough facilities and people with adequate expertise.
But he thinks it will all come out OK. Back in 2007, he notes, breast MRI was recommended for all women who were calculated (based on various risk factors) to have a more than 20% lifetime risk of developing breast cancer. Again, experts were worried there wasn’t the capacity to handle it. “Five years later, it’s pretty much sorted itself out,” he says.
Reitherman did a calculation recently and concluded that the California law, added to ones in other states, mean that 30% of the 300-plus million people in the U.S. are now covered by mandatory breast-density reporting laws. “It’s no longer a small thing. It’s huge, and it needs to be dealt with,” he says.
For now, the testing options for women likely will depend not only on the density of women’s breasts but also how they score on lifetime breast cancer risk assessments. (These do not yet factor in breast density, although scientists are working on that.)
If women want to know about their breast density and aren’t covered by mandatory breast density reporting laws, he adds, it’s easy enough: That information will be in their medical records and they are entitled to copies of these.
Finally, another word from Chung about what she’d like to see patients do:
“There are only certain things we can control. We can’t control that we are female and we can’t control our genetics. But we can control how much we exercise, we can control how much alcohol we drink, we can control how fat we are. We would want to get our vitamin D levels up to normal levels. And if we are on HRT and don’t need it, we can come off it.”
[For the record, 3:54 p.m. Sept. 27: An earlier version of this post incorrectly said that 318 million people in the U.S. would now be covered by breast density laws.]