The California Breast Density Information Group: A Collaborative Response to the Issues of Breast Density, Breast Cancer Risk, and Breast Density Notification Legislation

Published Online:https://doi.org/10.1148/radiol.13131217

The impact of breast density notification legislation is far reaching, and radiologists should take a proactive role in assessing the need for potential change in their practices and in translating currently available outcomes data into information for referring clinicians and patients that can be easily understood and accessed.

In anticipation of breast density notification legislation in the state of California, which would require notification of women with heterogeneously and extremely dense breast tissue, a working group of breast imagers and breast cancer risk specialists was formed to provide a common response framework. The California Breast Density Information Group identified key elements and implications of the law, researching scientific evidence needed to develop a robust response. In particular, issues of risk associated with dense breast tissue, masking of cancers by dense tissue on mammograms, and the efficacy, benefits, and harms of supplementary screening tests were studied and consensus reached. National guidelines and peer-reviewed published literature were used to recommend that women with dense breast tissue at screening mammography follow supplemental screening guidelines based on breast cancer risk assessment. The goal of developing educational materials for referring clinicians and patients was reached with the construction of an easily accessible Web site that contains information about breast density, breast cancer risk assessment, and supplementary imaging. This multi-institutional, multidisciplinary approach may be useful for organizations to frame responses as similar legislation is passed across the United States.

© RSNA, 2013

Online supplemental material is available for this article.

References

  • 1. D’Orsi CJ, Mendelson EB, Ikeda DM, et al. Breast imaging reporting and data system: ACR BI-RADS—breast imaging atlas. Reston, Va: American College of Radiology, 2003. Google Scholar
  • 2. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. Breast imaging reporting and data system: ACR BI-RADS—breast imaging atlas. 5th ed. Reston, Va: American College of Radiology, 2013 (in press). Google Scholar
  • 3. U.S. Census Bureau. State and county quickfacts. http://quickfacts.census.gov/qfd/states/06000.html. Accessed March 11, 2013. Google Scholar
  • 4. Mammography Quality Standards Act and Programs; US Food and Drug Administration. http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/default.htm. Accessed March 11, 2013. Google Scholar
  • 5. NCI-funded Breast Cancer Surveillance Consortium. (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, U01CA70040, HHSN261201100031C). Breast Cancer Surveillance Consortium Web site. http://breastscreening.cancer.gov/data/mammography_data.html. Accessed March 11, 2013. Google Scholar
  • 6. Sickles EA, Miglioretti DL, Ballard-Barbash R, et al. Performance benchmarks for diagnostic mammography. Radiology 2005;235(3):775–790. LinkGoogle Scholar
  • 7. Egan RL, Mosteller RC. Breast cancer mammography patterns. Cancer 1977;40(5):2087–2090. Crossref, MedlineGoogle Scholar
  • 8. Whitehead J, Carlile T, Kopecky KJ, et al. Wolfe mammographic parenchymal patterns: a study of the masking hypothesis of Egan and Mosteller. Cancer 1985;56(6):1280–1286. Crossref, MedlineGoogle Scholar
  • 9. van Gils CH, Otten JD, Verbeek AL, Hendriks JH. Mammographic breast density and risk of breast cancer: masking bias or causality? Eur J Epidemiol 1998;14(4):315–320. Crossref, MedlineGoogle Scholar
  • 10. Buist DS, Porter PL, Lehman C, Taplin SH, White E. Factors contributing to mammography failure in women aged 40-49 years. J Natl Cancer Inst 2004;96(19):1432–1440. Crossref, MedlineGoogle Scholar
  • 11. Jackson VP, Hendrick RE, Feig SA, Kopans DB. Imaging of the radiographically dense breast. Radiology 1993;188(2):297–301. LinkGoogle Scholar
  • 12. Pinsky RW, Helvie MA. Mammographic breast density: effect on imaging and breast cancer risk. J Natl Compr Canc Netw 2010;8(10):1157–1164; quiz 1165. Crossref, MedlineGoogle Scholar
  • 13. Carney PA, Miglioretti DL, Yankaskas BC, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003;138(3):168–175. Crossref, MedlineGoogle Scholar
  • 14. Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA 1996;276(1):33–38. Crossref, MedlineGoogle Scholar
  • 15. Corsetti V, Houssami N, Ghirardi M, et al. Evidence of the effect of adjunct ultrasound screening in women with mammography-negative dense breasts: interval breast cancers at 1 year follow-up. Eur J Cancer 2011;47(7):1021–1026. Crossref, MedlineGoogle Scholar
  • 16. Leconte I, Feger C, Galant C, et al. Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density. AJR Am J Roentgenol 2003;180(6):1675–1679. Crossref, MedlineGoogle Scholar
  • 17. Sickles EA. The use of breast imaging to screen women at high risk for cancer. Radiol Clin North Am 2010;48(5):859–878. Crossref, MedlineGoogle Scholar
  • 18. Boyd NF, Byng JW, Jong RA, et al. Quantitative classification of mammographic densities and breast cancer risk: results from the Canadian National Breast Screening Study. J Natl Cancer Inst 1995;87(9):670–675. Crossref, MedlineGoogle Scholar
  • 19. Byrne C, Schairer C, Wolfe J, et al. Mammographic features and breast cancer risk: effects with time, age, and menopause status. J Natl Cancer Inst 1995;87(21):1622–1629. Crossref, MedlineGoogle Scholar
  • 20. Ursin G, Ma H, Wu AH, et al. Mammographic density and breast cancer in three ethnic groups. Cancer Epidemiol Biomarkers Prev 2003;12(4):332–338. MedlineGoogle Scholar
  • 21. Vacek PM, Geller BM. A prospective study of breast cancer risk using routine mammographic breast density measurements. Cancer Epidemiol Biomarkers Prev 2004;13(5):715–722. Crossref, MedlineGoogle Scholar
  • 22. Boyd NF, Martin LJ, Sun L, et al. Body size, mammographic density, and breast cancer risk. Cancer Epidemiol Biomarkers Prev 2006;15(11):2086–2092. Crossref, MedlineGoogle Scholar
  • 23. Boyd NF, Guo H, Martin LJ, et al. Mammographic density and the risk and detection of breast cancer. N Engl J Med 2007;356(3):227–236. Crossref, MedlineGoogle Scholar
  • 24. Eddy D. Screening for breast cancer. In: Eddy D, ed. Common screening tests. Philadelphia, Pa: American College of Physicians, 1991; 229–254. Google Scholar
  • 25. Tabár L, Vitak B, Chen TH, et al. Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology 2011;260(3):658–663. LinkGoogle Scholar
  • 26. Smith RA, Duffy SW, Gabe R, Tabar L, Yen AM, Chen TH. The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am 2004;42(5):793–806, v. Crossref, MedlineGoogle Scholar
  • 27. Smith RA, Brooks D, Cokkinides V, Saslow D, Brawley OW. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin 2013;63(2):88–105. Google Scholar
  • 28. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57(2):75–89. Crossref, MedlineGoogle Scholar
  • 29. Mainiero MB, Lourenco A, Mahoney MC, et al. ACR appropriateness criteria breast cancer screening. J Am Coll Radiol 2013;10(1):11–14. Crossref, MedlineGoogle Scholar
  • 30. Bevers TB, Anderson BO, Bonaccio E, et al. NCCN clinical practice guidelines in oncology: breast cancer screening and diagnosis. J Natl Compr Canc Netw 2009;7(10):1060–1096. Crossref, MedlineGoogle Scholar
  • 31. Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA 2012;307(13):1394–1404. Crossref, MedlineGoogle Scholar
  • 32. Nothacker M, Duda V, Hahn M, et al. Early detection of breast cancer: benefits and risks of supplemental breast ultrasound in asymptomatic women with mammographically dense breast tissue—a systematic review. BMC Cancer 2009;9:335. Crossref, MedlineGoogle Scholar
  • 33. Sardanelli F, Podo F, Santoro F, et al. Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk Italian 1 study): final results. Invest Radiol 2011;46(2):94–105. Crossref, MedlineGoogle Scholar
  • 34. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008;299(18):2151–2163. Crossref, MedlineGoogle Scholar
  • 35. Hooley RJ, Greenberg KL, Stackhouse RM, Geisel JL, Butler RS, Philpotts LE. Screening US in patients with mammographically dense breasts: initial experience with Connecticut Public Act 09-41. Radiology 2012;265(1):59–69. LinkGoogle Scholar
  • 36. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267(1):47–56. LinkGoogle Scholar
  • 37. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013;14(7):583–589. Crossref, MedlineGoogle Scholar
  • 38. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010;7(1):18–27. Crossref, MedlineGoogle Scholar
  • 39. Berg WA. Supplemental screening sonography in dense breasts. Radiol Clin North Am 2004;42(5):845–851, vi. Crossref, MedlineGoogle Scholar
  • 40. Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 2005;23(33):8469–8476. Crossref, MedlineGoogle Scholar
  • 41. Lehman CD, Isaacs C, Schnall MD, et al. Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study. Radiology 2007;244(2):381–388. LinkGoogle Scholar
  • 42. Sardanelli F, Podo F, D’Agnolo G, et al. Multicenter comparative multimodality surveillance of women at genetic-familial high risk for breast cancer (HIBCRIT study): interim results. Radiology 2007;242(3):698–715. LinkGoogle Scholar
  • 43. Warner E, Plewes DB, Hill KA, et al. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 2004;292(11):1317–1325. Crossref, MedlineGoogle Scholar
  • 44. Weigert J, Steenbergen S. The connecticut experiment: the role of ultrasound in the screening of women with dense breasts. Breast J 2012;18(6):517–522. Crossref, MedlineGoogle Scholar
  • 45. Parris T, Wakefield D, Frimmer H. Real world performance of screening breast ultrasound following enactment of Connecticut Bill 458. Breast J 2013;19(1):64–70. Crossref, MedlineGoogle Scholar

Article History

Received June 6, 2013; revision requested July 19; revision received and final version accepted August 8.
Published online: Dec 2013
Published in print: Dec 2013