Primary Care Provider Experience with Breast Density Legislation in Massachusetts

The Level of Awareness Among Healthcare Practitioners Regarding the Relationship Between Breast Density and Breast Cancer

Background Breast cancer is the most prevalent cancer in women, accounting for around 23% of all cancer-related deaths across 140 nations. The awareness about breast density (BD) has a significant impact on early diagnosis of breast cancer. Aim and objective This study aims to assess the awareness of healthcare providers about BD in King Abdullah Medical City. Methods This is an analytical cross-sectional questionnaire-based study among the healthcare practitioners of KAMC in Makkah, Saudi Arabia. Questions measured knowledge about BD and a pass mark indicated participant awareness. The collected data were analyzed using SPSS, and a chi-square test used for bivariate analysis. Results Out of 124 participants, 41% were well aware. Physicians (37% of the sample) were significantly more aware than allied healthcare practitioners and nurses (awareness: 59.6%, 33.3%, 30.4% respectively, (p = 0.03)). Regarding specialty, radiologists and surgeons had the top level of awareness (62% and 64%, respectively) as compared to oncologists (47.1%) and other specialties (29.7%), (p= 0.016). Those above 40 years of age were more aware than those below 40 years (awareness: 62.1% and 34%, respectively, (p=0.007)). Non-significant factors included: gender, years of experience, screened versus non-screened, and receiving information before about BD (p > 0.05). Conclusion The results of this population-based study indicate the existence of moderate deficits in the general knowledge about BD and its relation to breast cancer. This might lead to a late diagnosis. The results showed no dramatic differences in the awareness among healthcare providers.

Sociodemographic Variations in Women's Reports of Discussions With Clinicians About Breast Density

Importance

Breast density notifications advise women to discuss breast density with their clinicians, yet little is known about such discussions.

Objectives

To examine the content of women's reports of breast density discussions with clinicians and identify variations by women's sociodemographic characteristics (age, income, state legislation status, race and ethnicity, and literacy level).

Design, Setting, and Participants

This US nationwide, population-based, random-digit dial telephone survey study was conducted from July 1, 2019, to April 30, 2020, among 2306 women aged 40 to 76 years with no history of breast cancer who underwent mammography in the prior 2 years and had heard the term dense breasts or breast density. Results were analyzed from a subsample of 770 women reporting a conversation about breast density with their clinician after their last mammographic screening. Statistical analysis was conducted in April and July 2023.

Main Outcomes and Measures

Survey questions inquired whether women's clinicians had asked about breast cancer risk or their worries or concerns about breast density, had discussed mammography results or other options for breast cancer screening or their future risk of breast cancer, as well as the extent to which the clinician answered questions about breast density.

Results

Of the 770 women (358 [47%] aged 50-64 years; 47 Asian [6%], 125 Hispanic [16%], 204 non-Hispanic Black [27%], 317 non-Hispanic White [41%], and 77 other race and ethnicity [10%]) whose results were analyzed, most reported that their clinicians asked questions about breast cancer risk (88% [670 of 766]), discussed mammography results (94% [724 of 768]), and answered patient questions about breast density (81% [614 of 761]); fewer women reported that clinicians had asked about worries or concerns about breast density (69% [524 of 764]), future risk of breast cancer (64% [489 of 764]), or other options for breast cancer screening (61% [459 of 756]). Women's reports of conversations varied significantly by race and ethnicity; non-Hispanic Black women reported being asked questions about breast cancer risk more often than non-Hispanic White women (odds ratio [OR], 2.08 [95% CI, 1.05-4.10]; P = .04). Asian women less often reported being asked about their worries or concerns (OR, 0.42 [95% CI, 0.20-0.86]; P = .02), and Hispanic and Asian women less often reported having their questions about breast density answered completely or mostly (Asian: OR, 0.28 [95% CI, 0.13-0.62]; P = .002; Hispanic: OR, 0.48 [95% CI, 0.27-0.87]; P = .02). Women with low literacy were less likely than women with high literacy to report being asked about worries or concerns about breast density (OR, 0.64 [95% CI, 0.43-0.96]; P = .03), that mammography results were discussed with them (OR, 0.32 [95% CI, 0.16-0.63]; P = .001), or that their questions about breast density were answered completely or mostly (OR, 0.51 [95% CI, 0.32-0.81]; P = .004).

Conclusions and Relevance

In this survey study, although most women reported that their clinicians counselled them about breast density, the unaddressed worries or concerns and unanswered questions, especially among Hispanic and Asian women and those with low literacy, highlighted areas where discussions could be improved.

Breast cancer risk characteristics of women undergoing whole-breast ultrasound screening versus mammography alone

BACKGROUND

There are no consensus guidelines for supplemental breast cancer screening with whole-breast ultrasound. However, criteria for women at high risk of mammography screening failures (interval invasive cancer or advanced cancer) have been identified. Mammography screening failure risk was evaluated among women undergoing supplemental ultrasound screening in clinical practice compared with women undergoing mammography alone.

METHODS

A total of 38,166 screening ultrasounds and 825,360 screening mammograms without supplemental screening were identified during 2014-2020 within three Breast Cancer Surveillance Consortium (BCSC) registries. Risk of interval invasive cancer and advanced cancer were determined using BCSC prediction models. High interval invasive breast cancer risk was defined as heterogeneously dense breasts and BCSC 5-year breast cancer risk ≥2.5% or extremely dense breasts and BCSC 5-year breast cancer risk ≥1.67%. Intermediate/high advanced cancer risk was defined as BCSC 6-year advanced breast cancer risk ≥0.38%.

RESULTS

A total of 95.3% of 38,166 ultrasounds were among women with heterogeneously or extremely dense breasts, compared with 41.8% of 825,360 screening mammograms without supplemental screening (p < .0001). Among women with dense breasts, high interval invasive breast cancer risk was prevalent in 23.7% of screening ultrasounds compared with 18.5% of screening mammograms without supplemental imaging (adjusted odds ratio, 1.35; 95% CI, 1.30-1.39); intermediate/high advanced cancer risk was prevalent in 32.0% of screening ultrasounds versus 30.5% of screening mammograms without supplemental screening (adjusted odds ratio, 0.91; 95% CI, 0.89-0.94).

CONCLUSIONS

Ultrasound screening was highly targeted to women with dense breasts, but only a modest proportion were at high mammography screening failure risk. A clinically significant proportion of women undergoing mammography screening alone were at high mammography screening failure risk.

Ensuring Clarity and Understandability of the FDA's Breast Density Notifications

This Viewpoint discusses the use of breast density notifications to inform women with dense breast tissue of the potential need for supplemental cancer screening, as well as the need to ensure that such notifications are clear and understandable to women of all language backgrounds, literacy levels, educational levels, and socioeconomic backgrounds.

Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening

Importance

Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density.

Objective

To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction.

Design, Setting, and Participants

This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020.

Main Outcomes and Measures

Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk.

Results

Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk.

Conclusions and Relevance

In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.

Australian General Practitioners' Current Knowledge, Understanding, and Feelings Regarding Breast Density Information and Notification: A Cross-Sectional Study

BACKGROUND

There is a lack of evidence around Australian general practitioners' (GPs) views of issues surrounding breast density. The current study aimed to quantitatively assess GPs' current knowledge, understanding, and feelings around breast density information and notification.

METHODS

This study involved a cross-sectional survey using an online platform to collect quantitative data from Australian GPs. Survey data were analysed with descriptive statistics.

RESULTS

A total 60 responses from GPs were analysed. Most (n = 58; 97%) had heard or read about breast density and nearly 90% (n = 52; 87%) have had discussions about breast density with patients. Three-quarters (n = 45; 75%) were supportive of making breast density notification mandatory for patients with dense tissue and a similar proportion (n = 45/58; 78%) felt they need or want more education on breast density.

CONCLUSIONS

There is strong support for notifying patients of breast density, and interest in further education and training among the surveyed GPs. As GPs play a central role in cancer prevention and control, their involvement in discussions related to breast density notification, evaluation and appraisal of evidence, development of communication strategies, and participation in ongoing research on the topic will be indispensable.

Evaluating educational interventions to increase breast density awareness among Latinas: A randomized trial in a Federally Qualified Health Center

BACKGROUND

The objective of this randomized trial was to evaluate the short-term effect of bilingual written and interpersonal education regarding mammographic breast density (MBD).

METHODS

Latinas aged 40 to 74 years who were presenting for screening mammography were recruited and randomized 1:1:1 to receive a letter with their mammogram and MBD results (usual care [UC]), a letter plus a brochure (enhanced care [ENH]), or a letter plus a brochure and telephonic promotora education (interpersonal care [INT]). Surveys were administered at enrollment (T₀ ) and 2 weeks to 6 months after intervention delivery (T₁ ). Differences were assessed with χ² , Kruskal-Wallis, and McNemar tests and pairwise comparisons as appropriate. INT metrics and audio recordings were analyzed with descriptive statistics and qualitative content analysis.

RESULTS

Between October 2016 and October 2019, 943 of 1108 Latina participants (85%) completed both surveys. At T₁ , INT participants were more likely (P < .001) to report seeing their MBD results in the letter (70.2%) than UC (53.1%) or ENH participants (55.1%). The percentage of INT women who reported speaking with a provider about MBD (29.0%) was significantly greater (P < .001) than the percentage of UC (14.7%) or ENH participants (15.6%). All groups saw significant (P < .001) but nondifferential improvements in their knowledge of MBD as a masking and risk factor. In the INT group, the promotora delivered education to 77.1% of the 446 participants randomized to INT and answered questions at 28.3% of the encounters for an average of $4.70 per participant.

CONCLUSIONS

Among Latinas in a low-resource setting, MBD knowledge may increase with written or interpersonal education, but with modest investment, interpersonal education may better improve MBD awareness and prompt patient-provider discussions.

Breast Density Knowledge and Awareness Among Latinas in a Low-Resource Setting

PURPOSE

Latinas in low-resource settings face additional barriers to understanding mammographic breast density (MBD) implications. The authors compared MBD awareness and knowledge in Latinas from a safety-net clinic in Arizona with a national sample.

METHODS

Latinas 40 to 74 years of age were recruited within a safety-net clinic during screening mammography appointments from 2016 to 2019 (AZ cohort) and from a nationally representative online panel in 2017 (NS cohort). Surveys completed in either English or Spanish assessed awareness and knowledge of MBD. Chi-square tests and logistic regression were used for comparisons.

RESULTS

The NS cohort (n = 152) was older, more educated, more likely to have undergone prior mammography, and more likely to prefer English compared with the AZ cohort (n = 1,327) (P ≤ .03 for all) The NS cohort was more likely to be aware of MBD (32.6% versus 20.7%). Of those aware, the NS cohort was more likely to understand MBD's effect on masking (67.8% versus 37.0%) and breast cancer risk (72.2% versus 32.6%) compared with the AZ cohort (P ≤ .001 for all). Adjusting for age, education, screening history, and language, MBD awareness was similar between the two cohorts (adjusted odds ratio [ORadj], 0.95; P = .83), but knowledge of MBD as a masking factor (ORadj, 2.8; P = .03) and risk factor (ORadj, 7.2; P < .001) remained higher in the NS cohort compared with the AZ cohort.

CONCLUSIONS

Differences in MBD awareness, but not knowledge, between Latinas in a low-resource setting compared with a national sample could be explained by age, education, screening history, and language preference, underscoring the need for tailored approaches to MBD education among Latinas.

The Impact of Breast Density Information or Notification on Women's Cognitive, Psychological, and Behavioral Outcomes: A Systematic Review

BACKGROUND

Breast density (BD) is an independent risk factor for breast cancer and reduces the sensitivity of mammography. This systematic review aims to synthesize evidence from existing studies to understand the impact of BD information and/or notification on women's cognitive, psychological, and behavioral outcomes.

METHODS

Studies were identified via relevant database searches up to March 2020. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of the 1134 titles identified, 29 studies were included. Twenty-three studies were quantitative, including only 1 randomized controlled trial of women receiving BD information, and 6 were qualitative. Twenty-seven studies were conducted in the United States, with 19 conducted post-BD legislation. The overall results in terms of BD awareness, knowledge, attitudes, perceptions, and intentions were heterogeneous across included studies, with the strongest consistency demonstrated regarding the importance of communication with and involvement of health-care professionals. Together, the studies did, however, highlight that there is still limited awareness of BD in the community, especially in more socioeconomic disadvantaged communities, and limited knowledge about what BD means and the implications for women. Importantly, BD information in the context of overall breast cancer risk has not yet been studied.

CONCLUSIONS

There are important gaps in the understanding of the impact of BD information or notification on women and how best to communicate BD information to women. More high-quality evidence to inform both current and future practice related to BD is still needed.

General practitioners' (GPs) understanding and views on breast density in Australia: a qualitative interview study

OBJECTIVES

To understand general practitioners' (GPs') awareness and knowledge of mammographic breast density (BD) and their perspectives around information and potential notification of BD for women.

DESIGN

Qualitative study using semistructured telephone interviews. Interviews were audiorecorded, transcribed and analysed using framework analysis.

SETTING

Australia.

PARTICIPANTS

Australian GPs (n=30).

RESULTS

GPs had limited knowledge of BD and little experience discussing BD with women. There were mixed views on notification of BD with some GPs believing this information would help informed decision making about breast health and that women have the right to know any information about their bodies. While others were concerned about causing unnecessary anxiety and were worried about the uncertainty about what to advise women to do with this information, particularly in relation to supplemental breast screening. The need for an equitable system where all women are either notified or not, and also provided with publicly funded supplemental screening was raised by GPs. Overall, there was high interest in education, training and support around the topic of BD.

CONCLUSIONS

Australian GPs require education, support and evidence-based guidelines to have discussions with women with dense breasts and help manage their risk, especially if widespread notification is to be introduced in population-based screening programmes.

Breast Cancer Risk Assessment and Primary Prevention Advice in Primary Care: A Systematic Review of Provider Attitudes and Routine Behaviours

Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July-August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education.

Effect of an educational intervention on women's healthcare provider knowledge gaps about breast density, breast cancer risk, and screening

OBJECTIVES

We sought to assess the effect of an educational intervention, based on DenseBreast-info.org website content, on women's healthcare provider knowledge of breast density, its risk and screening implications, and comfort level discussing these topics with patients.

METHODS

US-based women's healthcare providers participated in a web-based pretest/posttest study from May 14, 2019 to September 30, 2019. Pretest included demographics; comfort/knowledge discussing breast density impact on risk and screening; and educational material. Posttest contained the same knowledge and comfort questions. We assessed mean pretest/posttest score and comfort level differences (paired t tests) and pretest/posttest knowledge gap differences (McNemar test). We evaluated associations of baseline characteristics with pretest score and score improvement using multiple linear regression, and associations with knowledge gaps using logistic regression.

RESULTS

Of 177 providers analyzed, 74.0% (131/177) were physicians and 71.8% (127/177) practiced obstetrics/gynecology. Average test score increased from 40.9% (5.7/14) responses correct pretest to 72.1% (10.1/14) posttest (P < 0.001). Pretest, 56.5% (100/177) knew women with extremely dense breasts have four-to-six-fold greater breast cancer risk than those with fatty breasts; 29.4% (52/177) knew risk increases with increasing glandular tissue; only 5.6% (10/177) knew 3D/tomosynthesis does not improve cancer detection in extremely dense breasts over 2D mammography; and 70.6% (125/177) would consider supplemental ultrasound after mammography in an average-risk 50-year old with dense breasts. Postintervention, these knowledge gaps resolved or reduced (all P < 0.005) and comfort in discussing breast density implications increased (all P < 0.001).

CONCLUSIONS

Important knowledge gaps about implications of breast density exist among women's healthcare providers, which can be effectively addressed with web-based education.

Breast Density Notification: A Systematic Review of the Impact on Primary Care Practitioners

Background: In the last decade, there has been an unprecedented amount of advocacy and attention surrounding the issue of breast density (BD) in relation to mammography screening. It is largely unknown what impact notifying women of their BD has had on clinical practice for PCPs. This systematic review aimed to synthesize evidence from existing studies to understand the impact of BD notification on primary care practitioners' (PCPs) knowledge, attitudes, and practice implications. Methods: Empirical studies were identified through relevant database searches (database inception to May 2020). Two authors evaluated the eligibility of studies, extracted and crosschecked data, and assessed the risk of bias. Results were synthesized in a narrative form. Results: Six studies of the 232 titles identified and screened were included. All studies were undertaken in the United States, with five conducted postlegislation in their respective states, and one study conducted in states that were both prelegislation and postlegislation. Five studies were quantitative, including four cross-sectional surveys, and one study was qualitative. Findings consistently demonstrated PCPs' overall lack of knowledge about BD, low level of comfort in discussing and managing patients in relation to dense breasts, and limited consensus on the most appropriate approach for managing women with dense breasts, particularly in relation to supplemental screening. Conclusions: This review highlights important gaps in PCPs' understanding of BD and confidence in having discussions with women about the implications of dense breasts. It identifies the need for high-quality research and the development of evidence-based guidelines to better support PCPs.

The effect of breast density on the missed lesion rate in screening digital mammography determined using an adjustable-density breast phantom tailored to Japanese women

OBJECTIVE

Despite the high risk of missing lesions in mammography, the missed lesion rate is yet to be clinically established. Further, no breast phantoms with adjustable breast density currently exist. We developed a novel, adjustable-density breast phantom with a composition identical to that of actual breasts, and determined the quantitative relationship between breast density and the missed lesion rate in mammography.

METHODS

An original breast phantom consisting of adipose- and fibroglandular-equivalent materials was developed, and a receiver operating characteristic (ROC) study was performed. Breast density, which is the fraction by weight of fibroglandular to total tissue, was adjusted to 25%, 50%, and 75% by arbitrarily mixing the two materials. Microcalcification, mass lesions, and spiculated lesions, each with unique characteristics, were inserted into the phantom. For the above-mentioned fibroglandular densities, 50 positive and 50 negative images for each lesion type were used as case samples for the ROC study. Five certified radiological technologists participated in lesion detection.

RESULTS

The mass-lesion detection rate, according to the area under the curve, decreased by 18.0% (p = 0.0001, 95% Confidence intervals [CI] = 0.1258 to 0.1822) and 37.8% (p = 0.0003, 95% CI = 0.2453 to 0.4031) for breast densities of 50% and 75%, respectively, compared to that for a 25% breast density. A similar tendency was observed with microcalcification; however, spiculated lesions did not follow this tendency.

CONCLUSIONS

We quantified the missed lesion rate in different densities of breast tissue using a novel breast phantom, which is imperative for advancing individualized screening mammography.

Understanding the response of mammography facilities to breast density notification

BACKGROUND

State-specific breast density notification legislation requires that women undergoing mammography be informed about breast density, with variation among states. Because mammography facilities are among the main points of contact for women undergoing mammography, research is needed to understand how facilities communicate information on breast density, cancer risk, and supplemental screening to women.

METHODS

A cross-sectional, 50-item, mailed survey of 156 American College of Radiology-certified mammography facilities in North Carolina was conducted in 2017 via the Tailored Design Method. Breast density notification practices, supplemental screening services, and patient educational materials were compared by supplemental screening availability via t tests and chi-square tests.

RESULTS

All responding facilities (n = 94; 60.3% response rate) notified women of their breast density in the mammography results letter. Breast cancer risk assessments were performed by 36.2% of the facilities, with risk information communicated in the final radiology report for the referring provider to discuss with the woman (79.4%) or in the results letter (58.8%). Supplemental breast cancer screening was offered by 63.8% of the facilities, with use based on multiple factors, including recommendations from the referring physician (63.3%) or reading radiologist (63.3%), breast density (48.3%), other risk factors (48.3%), and patient request (40.0%). Although 75.0% of the facilities offered breast density educational materials, only 36.6% offered educational materials on supplemental screening.

CONCLUSIONS

In a state with a breast density notification law, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women through various approaches. When supplemental screening is offered, facilities use multiple decision-making criteria rather than breast density alone.

Radiologic Technologist and Radiologist Knowledge Gaps about Breast Density Revealed by an Online Continuing Education Course

OBJECTIVE

We sought to identify provider knowledge gaps and their predictors, as revealed by a breast density continuing education course marketed to the radiology community.

METHODS

The course, continually available online during the study period of November 2, 2016 and December 31, 2018, includes demographics collection; a monograph on breast density, breast cancer risk, and screening; and a post-test. Four post-test questions were modified during the study period, resulting in different sample sizes pre- and postmodification. Multiple logistic regression was used to identify predictors of knowledge gaps (defined as > 25% of responses incorrect).

RESULTS

Of 1649 analyzable registrants, 1363 (82.7%) were radiologic technologists, 226 (13.7%) were physicians, and 60 (3.6%) were other nonphysicians; over 90% of physicians and over 90% of technologists/nonphysicians specialized in radiology. Sixteen of 49 physicians (32.7%) and 80/233 (34.3%) technologists/nonphysicians mistakenly thought the Gail model should be used to determine "high-risk" status for recommending MRI or genetic testing. Ninety-nine of 226 (43.8%) physicians and 682/1423 (47.9%) technologists/nonphysicians misunderstood the inverse relationship between increasing age and lifetime breast cancer risk. Fifty-two of 166 (31.3%) physicians and 549/1151 (47.7%) technologists/nonphysicians were unaware that MRI should be recommended for women with a family history of BRCA1/BRCA2 mutations. Tomosynthesis effectiveness was overestimated, with 18/60 (30.0%) physicians and 95/272 (34.9%) technologists/nonphysicians believing sensitivity nearly equaled MRI. Knowledge gaps were more common in technologists/nonphysicians.

CONCLUSIONS

Important knowledge gaps about breast density, breast cancer risk assessment, and screening exist among radiologic technologists and radiologists. Continued education efforts may improve appropriate breast cancer screening recommendations.

Mammographic density and breast cancer screening

Mammographic density, which is determined by the relative amounts of fibroglandular tissue and fat in the breast, varies between women. Mammographic density is associated with a range of factors, including age and body mass index. The description of mammographic density has been transformed by the digitalization of mammography, which has allowed automation of the assessment of mammographic density, rather than using visual inspection by a radiologist. High mammographic density is important because it is associated with reduced sensitivity for the detection of breast cancer at the time of mammographic screening. High mammographic density is also associated with an elevated risk of developing breast cancer. Mammographic density appears to be on the causal pathway for some breast cancer risk factors, but not others. Mammographic density needs to be considered in the context of a woman's background risk of breast cancer. There is intense debate about the use of supplementary imaging for women with high mammographic density. Should supplementary imaging be used in women with high mammographic density and a clear mammogram? If so, what modalities of imaging should be used and in which women? Trials are underway to address the risks and benefits of supplementary imaging.

Breast cancer supplemental screening: Women's knowledge and utilization in the era of dense breast legislation

Background

Given the growth in dense breast notification (DBN) legislation in the United States, we examined the association between different types of DBN laws and supplemental screening behaviors among women.

Methods

We surveyed in March–April 2018 a nationally representative sample of women aged 40‐59 years who received a routine screening mammogram in the past 18 months. Survey items included the following topics regarding supplemental screening: discussing risks or benefits with a provider, knowledge about the risk of false positives, and utilization. We grouped women by state DBN into non‐DBN, generic DBN (mentions breast density but not supplemental screening), DBN that mentions supplemental screening (DBN‐SS), and DBN with mandated insurance coverage for supplemental screening (DBN‐coverage), and estimated adjusted predicted probabilities for supplemental screening behaviors.

Results

Of 1641 women surveyed, 21.3% resided in non‐DBN, 41.2% in generic DBN, 25.8% in DBN‐SS, and 12.5% in DBN‐coverage states. Overall, 23.0% of respondents had discussed supplemental screening with a provider, 11.3% of whom discussed the risks, and 49.5% discussed the benefits. In adjusted analysis, women living in DBN‐coverage states were more likely to discuss supplemental screening (27.5%) than women in non‐DBN states (13.6%); pairwise contrast 13.8% (95% CI, 2.1% to 25.6%; P = .01). They were also more likely to have received supplemental screening for increased breast density (19.3%) compared to women living in non‐DBN (9.9%); contrast 9.4% (95% CI, 1.6% to 17.3%; P = .01), Generic DBN (7.3%); difference 12.0% (95% CI, 4.6% to 19.4%; P =< .001), and DBN‐SS (8.8%); contrast 10.5% (95% CI, 2.6% to 18.5%; P < .01) states.

Conclusions

Women in DBN‐coverage states were more likely to discuss supplemental screening with their providers, and to undergo supplemental screening, compared to women in states with other types of DBN laws, or without DBN laws.

Knowledge and Perception of Breast Density, Screening Mammography, and Supplemental Screening: in Search of "Informed"

BACKGROUND

As of 2019, 37 US states have breast density notification laws. No qualitative study to date has examined women's perspectives about breast density in general or by states with and without notification laws.

OBJECTIVE

Explore women's knowledge and perceptions of breast density and experiences of breast cancer screening across three states with and without notification laws.

DESIGN

Qualitative research design using four focus groups conducted in 2017.

PARTICIPANTS

Forty-seven women who had a recent normal mammogram and dense breasts in registry data obtained through the Breast Cancer Surveillance Consortium.

APPROACH

Focus groups were 90 min, audio recorded, and transcribed for analysis. Data were analyzed using mixed deductive and inductive coding.

KEY RESULTS

Women reported variable knowledge levels of personal breast density and breast density in general, even among women living in states with a notification law. A number of women were aware of the difficulty of detecting cancer with dense breasts, but only one knew that density increased breast cancer risk. Across all states, very few women reported receiving information about breast density during healthcare visits beyond being encouraged to get supplemental imaging or to pay for new mammography technology (i.e., breast tomosynthesis). Women offered more imaging or different technology held strong convictions that these were "better," even though knowledge of differences, effectiveness, or harms across technologies seemed limited. Women from all states expressed a strong desire for more information about breast density.

CONCLUSIONS

More research needs to be done to understand how the medical community can best assist women in making informed decisions related to breast density, mammography, and supplemental screening. Options to explore include improved breast density notifications and education materials about breast density, continued development of personalized risk information tools, strategies for providers to discuss evidence and options based on risk stratification, and shared decision-making.

Acceptability of an Interactive Computer-Animated Agent to Promote Patient-Provider Communication About Breast Density: a Mixed Method Pilot Study

BACKGROUND

Half of women undergoing mammography have dense breasts. Mandatory dense breast notification and educational materials have been shown to confuse women, rather than empower them.

OBJECTIVE

This study used a mixed method, multi-stakeholder approach to assess acceptability of an interactive, computer-animated agent that provided breast density information to women and changes in knowledge, satisfaction, and informational needs.

DESIGN

A pre-post survey and qualitative focus groups assessed the acceptability of the computer-animated agent among women. An anonymous, online survey measuring acceptability was delivered to a multi-stakeholder group.

PARTICIPANTS

English-speaking, mammography-eligible women ages 40-74 were invited and 44 women participated in one of nine focus groups. In addition, 14 stakeholders representing primary care, radiology, patient advocates, public health practitioners, and researchers completed the online survey.

INTERVENTIONS

A prototype of a computer-animated agent was delivered to women in a group setting; stakeholders viewed the prototype independently.

MAIN MEASURES

Data collected included open-ended qualitative questions that guided discussion about the content and form of the computer-animated agent. Structured surveys included domains related to knowledge, acceptability, and satisfaction. Stakeholder acceptability was measured with a series of statements about aspects of the intervention and delivery approach and are reported as the proportion of respondents who endorsed each statement.

KEY RESULTS

Six of 12 knowledge items demonstrated improvement post-intervention, satisfaction with the agent was high (81%), but the number of unanswered questions did not improve (67% vs. 54%, p = 0.37). Understanding of the distinction between connective and fatty tissue in the breast did not increase (30% vs. 26%, p = 0.48). Results of the multi-stakeholder survey suggest broad acceptability of the approach and agent.

CONCLUSIONS

Findings highlight the benefits of a brief interactive educational exposure as well as misperceptions that persisted. Results demonstrate the need for an evidence-based, accessible intervention that is easy to understand for patients.

Behavioral and psychological impact of returning breast density results to Latinas: study protocol for a randomized clinical trial

Background

Breast cancer is the most common cancer and the leading cause of cancer mortality among Latinas. As more is learned about the association between mammographic breast density (MBD) and breast cancer risk, a number of U.S. states adopted legislation and now a federal law mandates written notification of MBD along with mammogram results. These notifications vary in content and readability, though, which may limit their effectiveness and create confusion or concern, especially among women with low health literacy or barriers to screening. The purpose of this study is to determine whether educational enhancement of MBD notification results in increased knowledge, decreased anxiety, and adherence to continued mammography screening among Latina women in a limited-resources setting.

Methods

Latinas LEarning About Density (LLEAD) is a randomized clinical trial (RCT) comparing the impact of three notification approaches on behavioral and psychological outcomes in Latina women. Approximately 2000 Latinas undergoing screening mammography in a safety-net community clinic will be randomized 1:1:1 to mailed notification (usual care); mailed notification plus written educational materials (enhanced); or mailed notification, written educational materials, plus verbal explanation by a promotora (interpersonal). The educational materials and verbal explanations are available in Spanish or English. Mechanisms through which written or verbal information influences future screening motivation and behavior will be examined, as well as moderating factors such as depression and worry about breast cancer, which have been linked to diagnostic delays among Latinas. The study includes multiple psychological measures (anxiety, depression, knowledge about MBD, perceived risk of breast cancer, worry, self-efficacy) and behavioral outcomes (continued adherence to mammography). Measurement time points include enrollment, 2–4 weeks post-randomization, and 1 and 2 years post-randomization. Qualitative inquiry related to process and outcomes of the interpersonal arm and cost analysis related to its implementation will be undertaken to understand the intervention’s delivery and transferability.

Discussion

Legislation mandating written MBD notification may have unintended consequences on behavioral and psychological outcomes, particularly among Latinas with limited health literacy and resources. This study has implications for cancer risk communication and will offer evidence on the potential of generalizable educational strategies for delivering information on breast density to Latinas in limited-resource settings.

Trial registration

ClinicalTrials.gov, NCT02910986. Registered on 21 September 2016.

Items from the WHO Trial Registration Data Set can be found in this protocol.

Breast Density Awareness, Knowledge, and Attitudes Among US Women: National Survey Results Across 5 Years

PURPOSE

To assess changes in breast density (BD) awareness, knowledge, and attitudes among US women over a period of 5 years.

METHODS

Using a probability-based web panel representative of the US population, we administered an identical BD survey in 2012 and 2017 to women aged 40 to 74 years.

RESULTS

In 2017, 65.8% had heard of BD (versus 57.5% in 2012; P = .0002). BD awareness in both 2012 and 2017 was significantly associated with race, income, and education. Among women aware of BD in 2017, 76.5% had knowledge of BD's relationship to masking (versus 71.5% in 2012; P = .04); 65.5% had knowledge of BD's relationship to cancer risk (versus 58.5%; P = .009); and 47.3% had discussed BD with a provider (versus 43.1% in 2012; P = .13). After multivariable adjustment, residence in a state with BD legislation was associated in 2017 with knowledge of BD's relationship to risk but not to masking. Most women wanted to know their BD (62.5% in 2017 versus 59.8% in 2012; P = .46); this information was anticipated to cause anxiety in 44.8% (versus 44.9% in 2012; P = .96); confusion in 35.9% (versus 43.0%; P = .002); and feeling informed in 89.7% (versus 90.4%; P = .64). Over three-quarters supported federal BD legislation in both surveys. Response rate to the 2017 survey was 55% (1,502 of 2,730) versus 65% (1,506 of 2,311) in 2012.

CONCLUSION

Although BD awareness has increased, important disparities persist. Knowledge of BD's impact on risk has increased; knowledge about masking and BD discussions with providers have not. Most women want to know their BD, would not feel anxious or confused as a result of knowing, and would feel empowered to make decisions. The federal BD notification legislation presents an opportunity to improve awareness and knowledge and encourage BD conversations with providers.

Physician Knowledge, Attitudes, and Practices Regarding Breast Density

Background: Many states have enacted breast density laws, requiring that women be informed of their breast density status; however there is currently no consensus for screening guidelines or recommendations for women with dense breasts. The objective of this study is to access physician views about breast density and their practices for breast cancer screening of women with dense breasts in light of breast density laws. Materials and Methods: Setting: Academic medical centers, community and private practices mostly in New York City. Participants: Primary care providers (PCPs), radiologists and gynecologists. Procedure: We conducted the study through anonymous, self-administered surveys about physician knowledge, attitudes, and practices regarding screening of women with dense breasts. Bivariate and multivariate analyses were performed to assess differences between PCPs and specialists. Results: We received 155 responses of which 75% were female, 77% were attending-level physicians, 42% were PCPs, 28% were radiologists, 17% were gynecologists, and 9% other. Almost half of the respondents (48%) were unaware of breast density laws, and two-thirds (67%) felt they needed more education about breast density and supplemental screening. More than half of the respondents (62%) were unaware of the increased risk of breast cancer related to dense breasts. Compared to specialists, PCPs were less aware of their state's breast density laws (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.09-0.50) and of the increased breast cancer risk for women with dense breasts (OR 0.23; 95% CI 0.09-0.60). Conclusion: Breast density laws have not translated into greater knowledge of breast density and recommendations for supplemental screening among PCPs.

Strategies to Identify Women at High Risk of Advanced Breast Cancer During Routine Screening for Discussion of Supplemental Imaging

IMPORTANCE

Federal legislation proposes requiring that screening mammography reports to practitioners and women incorporate breast density information and that women with dense breasts discuss supplemental imaging with their practitioner given their increased risk of interval breast cancer. Instead of discussing supplemental imaging with all women with dense breasts, it may be more efficient to identify women at high risk of advanced breast cancer who may benefit most from supplemental imaging.

OBJECTIVE

To identify women at high risk of advanced breast cancer to target woman-practitioner discussions about the need for supplemental imaging.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study assessed 638 856 women aged 40 to 74 years who had 1 693 163 screening digital mammograms taken at Breast Cancer Surveillance Consortium (BCSC) imaging facilities from January 3, 2005, to December 31, 2014. Data analysis was performed from October 10, 2018, to March 20, 2019.

EXPOSURES

Breast Imaging Reporting and Data System (BI-RADS) breast density and BCSC 5-year breast cancer risk.

MAIN OUTCOMES AND MEASURES

Advanced breast cancer (stage IIB or higher) within 12 months of screening mammography; high advanced cancer rates (≥0.61 cases per 1000 mammograms) defined as the top 25th percentile of advanced cancer rates, and discussions per potential advanced cancer prevented.

RESULTS

A total of 638 856 women (mean [SD] age, 56.5 [8.9] years) were included in the study. Women with dense breasts (heterogeneously or extremely dense) accounted for 47.0% of screened women and 60.0% of advanced cancers. Low advanced cancer rates (<0.61 per 1000 mammograms) occurred in 34.5% of screened women with dense breasts. High advanced breast cancer rates occurred in women with heterogeneously dense breasts and a 5-year risk of 2.5% or higher (6.0% of screened women) and those with extremely dense breasts and a 5-year risk of 1.0% or higher (6.5% of screened women). Density-risk subgroups at high advanced cancer risk comprised 12.5% of screened women and 27.1% of advanced cancers. Density-risk subgroups had the fewest supplemental imaging discussions per potential advanced cancer prevented compared with a strategy based on dense breasts (1097 vs 1866 discussions). Women with heterogeneously dense breasts and a 5-year risk less than 1.67% (21.7% of screened women) had high rates of false-positive short-interval follow-up recommendation without undergoing supplemental imaging.

CONCLUSIONS AND RELEVANCE

The findings suggest that breast density notification should be combined with breast cancer risk so women at highest risk for advanced cancer are targeted for supplemental imaging discussions and women at low risk are not. BI-RADS breast density combined with BCSC 5-year risk may offer a more efficient strategy for supplemental imaging discussions than targeting all women with dense breasts.

Patient-Reported Breast Density Awareness and Knowledge after Breast Density Legislation Passage

RATIONALE AND OBJECTIVES

To determine awareness and knowledge of breast density and breast density legislation among women receiving routine mammography following passage of Massachusetts breast density legislation.

MATERIALS AND METHODS

A survey assessing breast density awareness and knowledge was administered to all women receiving screening mammography over two separate 1-week periods at an academic medical center following implementation of mandatory breast density notification. Survey questions queried sociodemographic factors, breast density knowledge, legislation awareness, and medical decision-making intent.

RESULTS

Of 1000 survey recipients, 338 (33.8%) returned their survey. Most women were surprised (207/338; 61.2%) to receive their breast density notification letter and unaware (302/338; 89.9%) of newly implemented breast density legislation. The majority (185/338; 54.7%) of survey respondents self-reported having dense breasts. Only 61.1% (113/185) of women with dense breasts reported that their personal breast density increased breast cancer risk, while only 60.0% (78/130) of women with non dense breasts reported that their personal breast density did not increase breast cancer risk. Significant differences between women with dense and nondense breasts were observed related to intention to follow-up with a health practitioner (118/185; 63.8% vs. 66/130; 50.8%, p = 0.03) and views on necessity of supplemental screening based on personal breast density (83/185; 45.1% vs. 20/130; 15.4%, p < 0.01).

CONCLUSIONS

Despite implementation of state breast density laws since 2009, confusion and misinformation about breast density persists among women receiving mammography screening. Innovative tools that more effectively inform patients, may be required to improve communication and patient understanding about breast density and subsequent breast care management.

"You probably can't feel as safe as normal women": Hispanic women's reactions to breast density notification

BACKGROUND

Patient advocacy has led to state-level legislative mandates for the release of personal mammographic breast density information to women undergoing screening mammography. More research is needed to understand the impact of this information on women's perceptions and mammography screening behavior.

METHODS

Semistructured interviews were conducted in English and Spanish with 24 self-identified Hispanic women who had undergone at least 1 mammogram since breast density notification was enacted in New York State. The women ranged in age from 43 to 63 years. Women were asked about their understanding and perceptions of the communication of New York State-mandated breast density information, and any actions they have taken or would take in response to this information. A content analysis of the qualitative data from the translated and transcribed interviews was conducted.

RESULTS

The majority of participants had no prior knowledge of breast density and expressed confusion and apprehension regarding the meaning of dense breasts when presented with the notification information. Many participants understood having dense breasts to be a serious and abnormal condition, and reported feelings of worry and vulnerability. Participants mostly expressed a strong interest in learning about breast density and obtaining additional and more frequent breast cancer screening tests. These behavioral intentions were consistent with participants' overall favorable view of breast cancer screening and a belief that their faith, as well as regular screening, can help to protect them from breast cancer morbidity and mortality.

CONCLUSIONS

Hispanic women conveyed proactive breast cancer screening intentions in response to breast density notification, despite inadequate comprehension of this information and negative emotional responses.

A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

Between-Race Differences in Supplemental Breast Cancer Screening Before and After Breast Density Notification Law

Guidelines recommend supplemental breast cancer screening for women at increased breast cancer risk; however, the passage of breast density notification laws may lead to supplemental screening that is incongruent with women's risk. We examined supplemental screening (ie, MRI, ultrasound, or tomosynthesis within 6 months of screening mammogram) among a sample of 2,764 African American (AA) and 691 European American (EA) women with negative or benign screening mammograms for whom we had data from both before and after implementation of breast density notification laws in the state of Michigan. Results indicated a 5-fold increase (from 0.14% to 0.7% of women) in supplemental screening among screen-negative women after passage of the law, driven in large part by an increase in supplemental screening among AA women. Breast density was more predictive of supplemental screening and had a marginally greater explanatory role in between-race differences in supplemental screening after passage of the law. Subgroup analyses (n = 250) indicated that whereas 5-year breast cancer risk was positively associated with supplemental screening before the law and negatively associated after the law for EA women, 5-year risk was not associated with supplemental screening either before or after passage of the law for AA women. Our findings suggest that whereas passage of the breast density notification laws may have motivated supplemental screening among AA women in particular, it lessened the consideration of breast cancer risk in supplemental screening decision making.

Should This Woman With Dense Breasts Receive Supplemental Breast Cancer Screening?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Breast cancer will develop in 12% of women during their lifetime and is the second leading cause of cancer death among U.S. women. Mammography is the most commonly used tool to screen for breast cancer. Considerable uncertainty exists regarding the age at which to begin screening and the optimal screening interval. Breast density is a risk factor for breast cancer. In addition, for women with dense breasts, small tumors may be missed on mammography and the sensitivity of screening is diminished. At the time of publication, 35 states had passed laws mandating that breast density be reported in the letters that radiologists send to women with their mammogram results. The mandated language may be challenging for patients to understand, and such reporting may increase worry for women who are told that their risk for breast cancer is higher than average on the basis of breast density alone. The U.S. Preventive Services Task Force and the American College of Radiology (ACR) have each issued guidelines that address breast cancer screening for women with dense breasts. Both organizations found insufficient evidence to recommend for or against magnetic resonance screening, whereas the ACR advises consideration of ultrasonography for supplemental screening. In this Beyond the Guidelines, 2 experts-a radiologist and a general internist-discuss these controversies. In particular, the discussants review the role of supplemental breast cancer screening, including breast ultrasonography or magnetic resonance imaging for women with dense breasts. Finally, the experts offer specific advice for a patient who finds her mammography reports confusing.

The impact of legislation mandating breast density notification - Review of the evidence

Breast density (BD) is an independent risk factor for breast cancer and reduces the sensitivity of mammography. The enactment of BD legislation in a majority of states in the USA mandating notification of risks associated with BD directly to women undergoing mammography has catapulted interest in BD among women, physicians, and policymakers. We therefore report a descriptive review of the evidence on the impact of enactment of BD legislation. Based on 22 eligible studies, we identified four broad themes of research: studies of the impact on screening rates, most showing increased utilisation of supplemental screening; studies exploring the effect on women, radiologists, or primary physicians (reporting heterogeneous effects on knowledge, awareness, perceptions, attitudes and behaviour; and changes in practice); few studies assessing the population impact (effect on screening outcomes or breast cancer stage); and studies of costs highlighting the economic burden from supplemental screening. Given that many of the studies were retrospective single institution studies (comparing pre- and post-legislation) or small surveys with a paucity of population-level studies, we highlight areas meriting additional research. The information described in this review can inform research priorities where BD legislation has been introduced and can be used to guide world-wide policy or practice decisions where BD legislation may be under debate or contemplation.