Is a Mammogram Enough?

In 2003, Nancy Cappello didn’t think she was at high risk for breast cancer. She was fit, healthy and had no close relatives who’d had the disease. Every year her mammograms were clear, and she’d receive the “happy gram,” as she calls it, reporting “no significant findings.” But in 2004, a few months after receiving her most recent “happy gram,” Cappello’s physician felt something unusual in her right breast and sent her for a mammogram, which again revealed nothing, and for an ultrasound—which detected a large tumor that turned out to be stage III breast cancer.

“I was shocked,” says Cappello. “I asked, ‘What happened?’” Her physician informed her that she had “dense” breasts, putting her at an increased risk for cancer. Studies show that the cancer risk for women with dense breasts is four to six times higher than for women without dense breasts. She also learned that mammography alone can miss 48 percent of cancers in women whose breast tissue is composed of dense (connective) tissue rather than nondense (fatty) tissue. Why? Because mammogram images of dense breasts are much harder to read and interpret. Fat shows up as black on a mammogram image. But both dense tissue and cancer show up as white. Consequently, lesions and tumors can be hidden or obscured by tissue density. It’s estimated that 50 percent of women have dense breasts, which are loosely associated with age (75 percent of women in their 30s have dense breasts; 25 percent of women in their 70s do.)

Cappello’s cancer had been growing for five years, and had traveled to her lymph nodes. If her cancer had been found earlier, she might not have had to endure a mastectomy, reconstruction, eight rounds of chemo and 24 radiation treatments. Today, Cappello is healthy, but she’s still angry that she never knew about her higher cancer risk due to her breast density. Nor did she know anything about a mammogram’s diminished capability to detect cancer in some cases.

As a result of her experience, Cappello founded Are You Dense?, a nationwide advocacy group dedicated to informing women about breast composition. Her foundation has successfully helped to enact Breast Density Notification Laws in 12 states (Connecticut, Texas, Virginia, New York, California, Hawaii, Maryland, Tennessee, Alabama, Nevada, Oregon and North Carolina), which mandate that doctors must inform women about their breast composition and density. What if you don’t live in one of those states? “Ask for a copy of the mammogram report that the radiologist sends to your referring physician,” says Cappello. “On it there will be information about your breast composition.”

If you do have dense breasts—or other factors that may increase your risk for breast cancer, such as a family history of the disease—discuss it with your doctor and ask whether you should look into other screening and diagnostic tests in addition to your yearly mammogram. These adjunct tests address the limitations of the standard mammogram and help doctors provide better care for their patients. Here are some of the emerging technologies you’ll want to know about:

• Tomosynthesis is a three-dimensional (3D) imaging allows doctors to see problem areas more clearly than in the standard 2-D mammogram.
• ABUS (automated breast ultrasound) uses high frequency sound waves to provide physicians with a 3-D image of your entire breast.
• CESM (contrast-enhanced spectral mammography) highlights areas of unusual blood flow patterns in breast tissue, which can be an indication of cancer.

_ Nancy Gottesman is a freelance writer and mother of one in Los Angeles._

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