Monday, June 5, 2023
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 0.25 ABIM MOC points
Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)
Physician Assistant - 0.25 AAPA hour(s) of Category I credit
IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit
This activity is intended for obstetricians/gynecologists/women’s health clinicians, hematologists/oncologists, family medicine/primary care clinicians, public health and prevention officials, nurses, physician assistants, and other members of the healthcare team for women with high breast density.
The goal of this activity is for learners to be better able to describe women’s perception of breast density compared with other breast cancer risks and their understanding of risk reduction.
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Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.00 contact hours are in the area of pharmacology.
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CME / ABIM MOC / CE Released: 4/28/2023
Valid for credit through: 4/28/2024
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Dense breasts, containing more glandular than fatty tissue, is an independent, nonmodifiable risk factor for breast cancer and can mask cancer on mammograms. Screening mammography detects it in in 40% to 50% of women.
Depending on degree of density, dense breast tissue is linked to 1.2-fold to 4-fold higher breast cancer risk vs 2-fold higher risk with first-degree family history of breast cancer. Other known risk factors include obesity, alcohol intake, parity, and history of breast biopsy.
A qualitative study of breast cancer screening-aged women found that few women identified breast density as a risk factor for breast cancer.
Most women did not feel confident they knew what actions could mitigate breast cancer risk, leading researchers to the conclusion that comprehensive education about breast cancer risks and prevention strategies are needed.
The study was published earlier this year in JAMA Network Open.[1]
"Forty [percent] to 50% of women who undergo mammography fall into the two highest breast density categories," said one of the study's authors, Christine Gunn, PhD, of the Dartmouth Institute for Health Policy and Clinical Practice, New Hampshire "Breast cancer risk increases from 1.2-4.0 times depending on the level of breast density. By comparison, a first-degree family history of breast cancer, particularly in premenopausal women, confers a two-fold higher breast cancer risk."
Gunn's study is based on a survey of 2306 women (between the ages of 40 and 76 years) that was conducted between 2019 and 2020. The goal was to determine how well women understood cancer risks associated with dense breast tissue. The final analysis included 1858 women (9% Asian, 27% Black, 14% Hispanic, 43% White, and 7% other race or ethnicity).
Breast density was thought to be a greater risk than not having children, drinking daily, and having had a prior breast biopsy, according to 52%, 53%, and 48% of respondents, respectively. Breast density was believed to be a lesser breast cancer risk than having a first-degree relative with breast cancer by 93% of women, and 65% of women felt it was a lesser risk than being overweight or obese.
Of the 61 women who completed follow-up interviews, 6 described breast density as a contributing factor to breast cancer risk, and 17 women did not know whether it was possible to reduce their breast cancer risk.
Doctors Must Notify Patients in WritingBreast tissue falls under 1 of 4 categories: fatty tissue, scattered areas of dense fibroglandular tissue, many areas of glandular and connective tissue, or extremely dense tissue. The tissue is considered dense if it falls under heterogeneously dense or extremely dense, and in those cases, follow-up testing with ultrasound or magnetic resonance imaging (MRI) may be necessary. This is important, Gunn said, because dense tissue can make "it harder to find cancers because connective tissue appears white on the mammogram, potentially masking tumors."
Prior studies have found that many clinicians are uncomfortable counseling patients on the implications of breast density and cancer risk, the authors wrote.
Under the Mammography Quality Standards Act,[2] which was updated on March 10, the FDA requires that patients be provided with a mammography report summary that "identifies whether the patient has dense or nondense breast tissue."
The report, which should be written in lay language, should also specify the "significance" of the dense tissue.
Although some states mandate notification regardless of the density level, most only notify women if heterogeneously dense or extremely dense tissue has been identified, Gunn said, but the rules are inconsistent, she added. In some facilities in Massachusetts, for example, women may receive a mammography report letter and a separate breast density letter.
"For some, it has been really confusing. They received a letter saying that their mammography was normal and then another one saying that they have dense breasts -- resulting in a lot of uncertainty and anxiety. We don't want to overly alarm people. We want them to understand their risk," she said.
Breast density can be considered among other risk factors, including alcohol use, obesity, diet, parity, prior breast biopsy, and inherited unfavorable genetic mutations.
"If the total lifetime risk is above 20%, that opens up further screening options, such as a breast MRI, which will catch more cancers than a breast mammogram by itself," Gunn said.
"The challenges for physicians and patients around collecting and understanding breast density information in the context of other risk factors can potentially lead to disparities in who gets to know their risk and who doesn't," Gunn said.
It would be possible, she speculated, to create or use existing risk calculators integrated into medical records and populated with information gathered in premammography visit questionnaires. Ideally, a radiologist could hand the patient results in real time at the end of the mammography visit, integrating risk estimates with mammography findings to make recommendations.
This study was supported by grant RSG-133017-CPHPS from the American Cancer Society.
