A new state law that took effect Tuesday requires doctors to notify women when routine mammograms detect dense tissue that can put women at increased risk for breast cancer and make cancer harder to spot.
But it’s unknown whether Illinois and the 35 other states that have adopted similar laws will save lives through their actions or just put more women through anxiety and potentially unnecessary and harmful follow-up procedures when women with dense breasts pressure their doctors for additional testing.
“I do think this is positive, especially where we are in 2019,” said Dr. Daniel Shekleton, a radiologist who is the lead interpreting physician over breast imaging at Memorial Medical Center in Springfield. “The patients these days are more in control of their health care.”
Shekleton said he supported House Bill 4392, which received no opposition in the General Assembly and was signed into law by Gov. Bruce Rauner.
He noted, however, that Memorial’s mammography patients with dense breast tissue have been notified about their status in writing the past two years as a voluntary step by Memorial and the Clinical Radiologists physician group practicing at the 500-bed hospital.
The law requires providers of mammography services to include specific information in letters to patients if doctors deem those patients among the 50 percent of women with dense breast tissue.
Breasts contain glands, fibrous tissue and fat. Dense breasts contain a smaller proportion of fat and more fibrous tissue.
“Dense breast tissue is normal,” the law states in a section containing suggested wording for letters to patients.
The law also suggests this passage: “Dense breast tissue can make it more difficult to detect cancer on a mammogram and may be associated with an increased risk for breast cancer. Despite these limitations, screening mammograms have been proven to save lives.”
The law says women should continue to have routine screening mammograms regardless of whether additional exams are recommended for them.
The legislation adds that women should contact their breast imaging health-care providers “for further information about dense breast tissue, as well as other breast-cancer risk factors.”
Patients undergoing mammography at HSHS St. John’s Hospital have been notified in writing for almost three years if they are identified with dense breast tissue, according to Dr. Deepa Cyriac, chief of the breast-imaging section at St. John’s and a member of Central Illinois Radiological Associates.
The law is a good idea to ensure more women get information that may help them speak with doctors about their care, Cyriac said.
“It’s just to raise awareness,” she said. “A lot of women are just more grateful in having this additional information.”
Shekleton and Cyriac said women’s primary care doctors and obstetricians/gynecologists have been informed by radiologists for decades when dense breast tissue is seen in screening mammograms. That information will continue to be shared with doctors, they said.
It’s not clear whether supplemental screening tests such as ultrasound or magnetic resonance imaging are justified in women with dense breast tissue, Shekleton said.
“It’s not an easy solution what women need to do next,” he said.
Screening ultrasounds and MRIs are more expensive than mammograms but generally are covered by health insurance.
Classifying breast tissue as dense isn’t an exact science, so different doctors’ opinions on the topic for certain patients may vary, Shekleton said.
“There are a lot of muddy issues,” he said.
Moreover, follow-up screenings can lead to more invasive procedures that may or may not detect cancer but cause pain and complications, as well as worry, he said.
Supplemental testing and the related ramifications sometimes are an unavoidable result of laws such as the one taking effect this month in Illinois, Cyriac said. Additional tests can result in “false positives” as well as early detection of breast cancer, she said.
Illinois law makes it likely that most additional screening tests are covered by health insurance, she said.
The notification of dense breast tissue for Memorial patients has resulted in some additional supplemental screening tests but not a significant number, Shekleton said.
He said he has spoken with obstetricians/gynecologists at Springfield Clinic and Memorial Physician Services — both groups are served by Clinical Radiologists — to make sure doctors and their patients are aware of the benefits and potential harms of supplemental tests when patients with dense breast tissue ask questions about their notification letters.
Cyriac said St. John’s has conducted more follow-up screening tests for patients with dense breast tissue, in part because of the notifications begun about three years ago but mostly because patients are educating themselves about dense breast tissue.
“People have sought out this technology,” she said.
However, doctors writing in the medical journal JAMA Internal Medicine in 2015 said state laws requiring notification of breast density don’t necessarily improve women’s understanding of breast-cancer risk, the limitations of mammography or outcomes for patients.
“Moreover, the laws create the unsubstantiated anticipation that additional testing is better for women,” doctors from Brigham and Women’s Hospital in Boston and the University of California at San Francisco wrote in the medical journal article.
The laws don’t deal with important risk factors for breast cancer such as age, family history of breast or ovarian cancer and genetic mutations, Drs. Jennifer Haas and Celia Kaplan wrote.
“Breast density notification laws may limit a broader understanding and discussion of personal risk, as well as the benefits and harms of different screening approaches,” the doctors wrote.
They note that women with extremely dense breast tissue have twice the relative risk of developing breast cancer compared to women with average breast density, but the overall cancer risk is relatively small.
The article says the “absolute, 5-year risk of breast cancer for a 45-year-old woman with average breast density, no family history of breast cancer and no history of prior breast biopsy is 0.7 percent” versus 1.3 percent for a woman with “extremely dense” breast tissue.
In addition, the doctors wrote that the increased focus on breast cancer screening “may divert attention from discussion of other health risks, such as risk factors for heart disease, which is the leading cause of death for women.”
Contact Dean Olsen at firstname.lastname@example.org or twitter.com/DeanOlsenSJR.