Breast Density: Standardization Needed

April 18, 2012

If physicians are required to tell patients when they have dense breasts, how do they determine what counts as a dense breast? Kwan-Hoong Ng, who wrote a commentary on the issue for Lancet Oncology, lays out the issues in this interview.

In 2010, Connecticut became the first state to require that providers inform patients about whether they had dense breast tissue. Texas followed suit in January, and at least 13 more states are expected to do so, including California.

There is now a nationwide discussion about the benefits and challenges of including this information in mammography reports. The sticking point has been how to convey breast density details in a standardized way.

In the April issue of Lancet Oncology, Kwan-Hoong Ng, a biomedical imaging professor at the University of Malaya Research Imaging Centre in Kuala Lumpur, Malaysia, and colleagues wrote a commentary, underscoring how important standardization is to realize the benefits of breast density reporting. Diagnostic Imaging spoke with Professor Ng via email about what the industry currently understands about breast density and why standardization is paramount.


Based on your knowledge and work, what do you recommend radiologists know about breast density?

Radiologists do know something about breast density right now because they classify or code it using BIRADS. But, it’s done subjectively. Dense breast tissue is always a diagnostic challenge, so they have to resort to ultrasound and MRI. At this point in time, education and greater awareness are necessary.


How much do you think is currently understood about breast density? More standardization is needed, but would you consider anything to be standardized now?

The current system is based on eye-balling, depending on one’s clinical experience and judgment. Furthermore, mammogram is a 2D projection of the 3D breast. Some information will be lost in reporting. For standardization to take place, we need some objective, reproducible way of measuring breast density. Thus, I discuss, in the commentary, the volumetric breast density and some potentially highly powerful software, based on years of research, to overcome this challenge.


Data about breast density is included in information given to patients, but little context is provided. What other information should radiologists give patients in order to make sure patients understand what the breast density means?

Radiologists need to provide some simple explanation of what breast density is. It consists of two components. The percentage of glandular tissue in the whole breast is the so-called breast density – glandularity, as we call it. It is an indicator of cancer risk, etc. Again, a lot of effort is needed to educate the people. Recall when the Mammography Quality Standards Act started. There was lots of publicity and awareness, but it still took so many years for acceptance and recognition.


What clinical benefits do you predict would materialize if a standardized protocol for reporting breast density to patients were put in place?

Standardized reporting helps in the proper management of patients in follow-up care. It saves cost by reducing unnecessary mammogram retakes or additional imaging modalities. It will also have a tremendous impact on breast health by improving communication among healthcare providers.


Can you expand your thoughts about what the short-term and long-term benefits of a standardized protocol would be?

In addition to the improvements in follow-up care, cost reduction, and improved communication among healthcare providers, a significant long-term benefit would be ultimately achieving the goal of early detection of breast cancer, as well as effective management to reduce the mortality rate among women.


Do you have any recommendations for how this protocol could be designed?

Yes. It will require a great deal of high-level coordination. The professional bodies, such as the American College of Radiology, the American Cancer Society, as well as many other stakeholders, must come together to craft the best recommendations.