By Leah Small
Capital News Service
[This story accompanies Law Would Improve Breast Cancer Detection.]
Initially, the legislation required women to be told their breast density after having a mammogram and contained this language: If a woman had dense tissue, her radiologist had to send her a letter suggesting that “supplementary screening tests may be beneficial.”
Doctors had some concerns about that wording.
The Virginia Chapter of the American College of Radiology expressed those concerns to Delegate Robert Orrock, sponsor of House Bill 83. Dr. Sterling Ransone, vice president of the Medical Society of Virginia, told a House subcommittee that he also saw problems with HB 83 and the identical Senate Bill 544, submitted by Sen. John Edwards, D-Roanoke.
“MSV and the American College of Radiology-Virginia Chapter worked with the bill patrons about physicians’ concerns about bill language as originally introduced. MSV is appreciative of Delegate Orrock’s and Sen. Edwards’s openness to improving the bill to ensure that women receive the relevant information they need about their breast health,” according to the medical society’s website.
After input from the doctors, the bills now say that women must receive a letter informing them that they may have dense breasts and that dense tissue “can hide cancer or other abnormalities.” Instead of stating that additional tests may be necessary, the bill says women “should contact your physician if you have any questions or concerns about this report.”
Dr. Gilda Cardenosa, a fellow with the Virginia Chapter of the American College of Radiology, is satisfied with the legislation’s new language.
She feared that the initial wording, recommending additional tests such as an MRI or ultrasound, might backfire: Some women might think mammograms were unnecessary or ineffective in the first place – and might stop getting annual mammograms.
Cardenosa emphasized that women should have regular mammograms.
“Even if you get a letter saying your breasts are dense, please don’t give up on mammograms. There are some cancers that we can only see on a mammogram,” she said. “The mammogram is sort of an infrastructure on which we can build other things.”
There’s another concern in wording the “breast density inform” letters: Officials don’t want to raise unnecessary fear in women who may have dense breasts.
“The fine line we are trying to walk here is providing sufficient information to the patient but without the panic,” Orrock said.
Cardenosa also cautioned that determining breast density is subjective. Since the breasts of most women have a combination of both fatty and dense tissue, and all breasts are different, it can be hard to determine breast density. One radiologist looking at an X-ray could call the breast tissue dense; another looking at the same film could call it fatty.
“The problem as I see it from my perspective is that this is, in some ways, quite nuanced,” Cardenosa said.
Two companies, Volpara and Hologic, recently developed technology to calculate breast density and remove the subjectivity. Cardenosa has not seen a lot of peer-reviewed literature on the technology. “I would be surprised if it is being widely used,” she said.
Cardenosa also wants women to realize that, like mammograms, ultrasounds and MRIs aren’t infallible: These tests also can fail to detect some cancers.
Standardization and quality of technology and personnel are other issues. Technologists performing the tests must be sure they cover the entire breast to get an accurate reading. Also, the quality of breast ultrasound technology may vary more from facility to facility than that of mammography. This is because mammography is kept to strict standards that do not apply to breast ultrasound under the federal Mammography Quality Standards Act.
Cardenosa recommends an MRI only when a woman has a risk factor such as a previous experience with cancer, a family history of cancer or atypical physiological changes.
Nancy Cappello, the cancer survivor who established the Are You Dense advocacy group, said too many women are unaware of their breast density.
“I could not believe that there was information about my body and my health that was kept from me,” she said. “My doctor knew it, my radiologist knew it, but I did not know it.”