Breast density legislation

Breast Density Awareness and Knowledge in a Mammography Screening Cohort of Predominantly Hispanic Women: Does Breast Density Notification Matter?

BACKGROUND

New York State law mandates that women with dense breasts receive a written notification of their breast density (BD) and its implications, but data on the impact of dense breast notification (DBN) on BD awareness and knowledge in diverse populations remain limited.

METHODS

Between 2016 and 2018, we collected survey and mammographic data from 666 women undergoing screening mammography in New York City (ages 40-60, 80% Hispanic, 69% Spanish-speaking) to examine the impact of prior DBN on BD awareness by sociodemographic and breast cancer risk factors, and describe BD knowledge by sources of information.

RESULTS

Only 24.8% of the overall sample and 34.9% of women receiving DBN had BD awareness. In multivariable models adjusting for DBN, awareness was significantly lower in women who were Spanish-speaking [OR, 0.16; 95% confidence interval (CI), 0.09-0.30 vs. English speakers], were foreign-born (OR, 0.31; 95% CI, 0.16-0.58 vs. U.S.-born), and had lower educational attainment (e.g., high school degree or less; OR, 0.14; 95% CI, 0.08-0.26 vs. college or higher degree). Women receiving DBN were more likely to be aware of BD (OR, 2.61; 95% CI, 1.59-4.27) but not more knowledgeable about the impact of BD on breast cancer risk and detection. However, women reporting additional communication about their BD showed greater knowledge in these areas.

CONCLUSIONS

DBN increases BD awareness disproportionately across sociodemographic groups.

IMPACT

Efforts to improve communication of DBN must focus on addressing barriers in lower socioeconomic and racially and ethnically diverse women, including educational and language barriers.

A web-based personalized risk communication and decision-making tool for women with dense breasts: Design and methods of a randomized controlled trial within an integrated health care system

BACKGROUND

Mammographic breast density is one of the strongest risk factors for breast cancer after age and family history. Mandatory breast density disclosure policies are increasing nationally without clear guidance on how to communicate density status to women. Coupling density disclosure with personalized risk counseling and decision support through a web-based tool may be an effective way to allow women to make informed, values-consistent risk management decisions without increasing distress.

METHODS/DESIGN

This paper describes the design and methods of Engaged, a prospective, randomized controlled trial examining the effect of online personalized risk counseling and decision support on risk management decisions in women with dense breasts and increased breast cancer risk. The trial is embedded in a large integrated health care system in the Pacific Northwest. A total of 1250 female health plan members aged 40-69 with a recent negative screening mammogram who are at increased risk for interval cancer based on their 5-year breast cancer risk and BI-RADS® breast density will be randomly assigned to access either a personalized web-based counseling and decision support tool or standard educational content. Primary outcomes will be assessed using electronic health record data (i.e., chemoprevention and breast MRI utilization) and telephone surveys (i.e., distress) at baseline, six weeks, and twelve months.

DISCUSSION

Engaged will provide evidence about whether a web-based personalized risk counseling and decision support tool is an effective method for communicating with women about breast density and risk management. An effective intervention could be disseminated with minimal clinical burden to align with density disclosure mandates. Clinical Trials Registration Number:NCT03029286.

Screening ultrasound as an adjunct to mammography in women with mammographically dense breasts

There are potential benefits and harms of screening ultrasound (US) to supplement mammographic screening of women with dense breast tissue. We conducted a comprehensive literature review of studies assessing the efficacy of screening US to supplement mammography among women with dense breasts. From a total of 189 peer-reviewed publications on the performance of screening US, 12 studies were relevant to our analysis. The reporting of breast cancer risk factors varied across studies; however, the study populations tended to be at greater than average risk for developing breast cancer. Overall, US detected an additional 0.3-7.7 cancers per 1000 examinations (median, 4.2) and was associated with an additional 11.7-106.6 biopsies per 1000 examinations (median, 52.2). Significant improvements in cancer detection in dense breasts have been achieved with the transition from film to digital mammography. Thus adjunctive screening with ultrasound should be considered in the context of current screening mammography performance. Clinicians should discuss breast density as 1 of several important breast cancer risk factors, consider the potential harms of adjunctive screening, and arrive at a shared decision consistent with each woman's preferences and values.

Mammographic breast density as a risk factor for breast cancer: awareness in a recently screened clinical sample

BACKGROUND

Breast density is an established, independent risk factor for breast cancer. Despite this, density has not been included in standard risk models or routinely disclosed to patients. However, this is changing in the face of legal mandates and advocacy efforts. Little information exists regarding women's awareness of density as a risk factor, their personal risk, and risk management options.

METHODS

We assessed awareness of density as a risk factor and whether sociodemographic variables, breast cancer risk factors. and perceived breast cancer risk were associated with awareness in 344 women with a recent screening mammogram at a tertiary care center.

FINDINGS

Overall, 62% of women had heard about density as a risk factor and 33% had spoken to a provider about breast density. Of the sample, 18% reported that their provider indicated that they had high breast density. Awareness of density as a risk factor was greater among White women and those with other breast cancer risk factors.

CONCLUSION

Our results suggest that although a growing number of women are aware of breast density as a risk factor, this awareness varies. Growing mandates for disclosure suggest the need for patient education interventions for women at increased risk for the disease and to ensure all women are equally aware of their risks.

Digital breast tomosynthesis changes management in patients seen at a tertiary care breast center

Objectives. To study factors that predict changes in management with digital breast tomosynthesis (DBT). Methods. The Institutional Review Board approved this HIPAA compliant study. 996 patients had DBT with full field digital mammography (FFDM). Univariate analysis evaluated predictors of management change and cancer detection. Results. DBT changed management in 109 of 996 (11%); 77 (71%) required less imaging. Recalled patients after abnormal FFDM screen were most likely to have management change—25% (24 of 97 patients) compared to 8% (13/163) of symptomatic patients and 10% (72/736) of screening patients (P < 0.001). Dense breasted patients had a higher likelihood of having DBT change management: 13% (68/526) compared to 9% (41/470) (P = 0.03). Of the 996 patients, 19 (2%) were diagnosed with breast cancer. 15 cancers (83%) were seen on FFDM and DBT; 3 (17%) were diagnosed after DBT (0.3%, 95%CI: 0.1–0.9%). One recurrence was in the skin and was not seen on DBT nor was it seen on FFDM. The increase in cancer detection rate was 17% for asymptomatic patients, 0% for symptomatic patients, and 100% for recalled patients. Conclusions. DBT increased cancer detection rate by 20% and decreased the recall rate in 8–25%. Advances in Knowledge. DBT led to a doubling of the cancer detection rate in recalled patients.