Keen to know more about breast density but don't want to wade through a bunch of technical papers? Well, we have the solution! This lecture by INFORMD member A/Prof Wendy Ingman, from the University of Adelaide, covers pretty much everything you want to know about breast density - what it is, what is the association with cancer, why it hides cancers on a mammogram, and the current Australian position on breast density.
The lecture was made for McGrath Breast Care Nurses and is part of a series of lectures on the McGrath Foundation eLearning platform which has received CPD accreditation from the Australian College of Nursing. The McGrath Foundation have kindly agreed to let InforMD share the lecture online so anyone wanting to learn about breast density can do so from the comfort of their own home. So grab a cup of coffee, sit back and enjoy!
Please be aware that since the lecture was filmed in May 2017, there have been some changes to the BreastScreen WA information on breast density. The updated information for women can be found here, and the updated information for GPs can be found here. A significant change is the addition of the following statement to the information for GPs regarding supplementary screening for women with dense breasts "Women at intermediate risk of breast cancer due to a family history, a personal history of breast cancer, or other risk factors including premalignant lesions such as lobular neoplasia may benefit from regular supplemental whole breast ultrasound."
Apparently I was lucky! Of course, to be diagnosed with cancer was a huge shock. However, what was clear was that without supplemental screening ultrasound, my tumour would not have been detected. Unfortunately, ultrasound is not offered in the national screening programme in the UK unless a woman presents symptoms. My next screening mammogram would have been 3 years on and the outcome would likely have been quite different.
Knowledge is Power
Immediately I began to research IDC. I needed to educate myself. As a retired teacher, I wanted to learn all about breast cancer. I was surprised and fascinated to discover the issue of dense breasts.
Why Does Breast Density Matter?
I discovered that breasts are made up of glandular and fatty tissue and whilst dense breasts are not abnormal, mammography is not as effective detecting cancers in women with highly dense breast tissue. On a mammogram image, dense tissue appears white, but so does cancer, almost like a fog. Cancers can go undetected and sometimes women are diagnosed later with interval cancers at a more advanced stage which require more treatment.
I live in France and national screening begins at the age of 50. For many years, mammograms and ultrasound have been coupled. If you receive a negative or clear mammogram, and you have dense breasts, it is likely that the radiologist will immediately carry out an ultrasound examination to be thorough. National screening public information leaflets state this to educate women on what to expect. First a mammogram, possibly followed by an ultrasound.
My Treatment - Positive Health Outcome
In July 2016, I had a simple operation, a lumpectomy to have the tumour removed and starting in September, I underwent 35 radiotherapy sessions. My breast cancer experience was strangely a 'good' one; and I constantly remind myself it could have been so different. I continue to have regular checks - mammograms AND ultrasound.
Breast Density Matters UK - Campaign
During my research, I found a woman in the UK, who had dense breasts. She had found a lump and she had decided to have a mastectomy. She discovered by chance (seeing her medical notes) that within the removed breast, there had been a large tumour hidden in her dense breast. I contacted her and discovered that she had begun a Breast Density campaign back in 2013. In fact, I found more women in the UK who had dense breasts; who had received 'normal' mammograms, and then later been diagnosed with more advanced cancers. I had avoided all of this. Not only was I lucky but I was totally compelled to do something. I decided to re-launch the Breast Density campaign.
In one year, Breast Density Matters UK has gained worldwide support from breast cancer survivors as well as breast cancer experts; surgeons, radiologists, scientists, and cancer organisations who promote patient empowerment. We believe that women NEED to be educated about their breast density in order that they can make an informed decision about their breast health. Doctors and other health experts also NEED to be educated on the related risks of dense breasts. We are attending conferences around the world and encouraging influencers in the world of cancer to educate and debate; ultimately promoting early detection.
I consider my breast cancer journey a short, 'easy' and pain-free experience. My inspiration and motivation comes from women who were not offered ultrasound on dense breasts; whose cancers were detected later; women who have undergone mastectomies; chemotherapy, reconstruction and whose cancers have perhaps spread, metastatic cancer. Indeed, women who have died from breast cancer. Every day in the UK, women are given 'clear' mammograms; whilst this may be true for some; for others, perhaps with dense breasts, there will be a cancer tumour present, left undetected. In the UK, up to 3,500 breast cancer tumours could be 'missed' each year.
Join the Breast Density Conversation!
Breast Density Matters UK - educating on dense breasts with the mission of early detection; reducing later stage cancer diagnoses and saving lives. The campaign is gaining momentum and if you would like to join the breast density conversation or you would like to know more please contact me. I would love to hear from you.
#TLC Touch, Look, Check.
 Laura Donnelly, Health Editor, 09 March 2016 http://www.telegraph.co.uk/news/nhs/12189095/NHS-breast-cancer-tests-miss-3.5k-tumours-a-year.html (calculation based on ASTOUND study findings: http://ascopubs.org/doi/abs/10.1200/JCO.2015.63.4147
Making an appointment
When you call up to make your appointment you will be asked details about the referral form given to you by your doctor. It is helpful if you inform the receptionist if there is anything that you feel may require a longer booking such as breast implants or a disability that may need the help of a second technician.
You will be asked to wear a two piece outfit to allow you to undress from the waist up and not to apply any deodorants or creams prior to the appointment as they may affect the image.
A female technician trained specifically in mammography will call you from the waiting room and take you to either a cubicle or the mammography room. Here they will confirm your identity and provide you with a gown. They will ask you to remove everything from the waist up. Jewellery is fine to stay on however long necklaces are best to either remove or swing round to the back. If you have long hair it is helpful if you are able to tie it back.
The standard mammogram
Once ready you will then be asked to remove the gown and step in front of the mammogram machine. If you don’t feel comfortable removing the whole gown you can remove one arm at a time.
Two images will be taken of each breast, one breast at a time. Both breasts are always imaged regardless of the symptom you are experiencing. They will take an image from the top of the breast looking down towards your feet and one from the side.
To be able to get you into the best position the technician will need to be quite hands on. This means touching your upper body several times. She will need to touch and move your breasts quite firmly to ensure that the entire breast is in the picture.
When imaging the breast for the top picture I will ask my patient to stand in front of the machine with their arms down by their side. The first breast is lifted and the machine adjusted to the correct height and the breast placed onto the x-ray unit. Your breast will be held firmly in place as a plastic paddle is lowered onto the breast and used to hold and compress the breast tissue.
Bad posture is encouraged in the mammography room, slouching forward sightly and sticking your bottom out will help relax the chest muscles and allow the most amount of breast tissue to be included in the image. We appreciate that it is a difficult situation to relax in but your technician will help and encourage you to do this. The more relaxed you are the softer your muscles are and the more breast tissue can be included in the picture. Relaxing your body will also reduce the discomfort that some women experience when compression is applied.
After the compression is applied the image is taken and this generally takes no more than about 30 seconds.
The side images are of the whole breast right up into the arm pit. You will be asked to place your arm across the machine and to lean in so that the unit is poking firmly into your arm pit. The breast will be held firmly up and out across the unit and again the compression paddle will be placed firmly down on the breast. For these the paddle is quite tight against your collar bone and ribs to ensure that no breast tissue is missed.
Occasionally your technician will decide that they need to take more images to ensure that the entire breast is covered but they will talk you through this process. Once she is happy that the whole breast has been imaged, you will be asked to put the gown back on and to wait until the images have been looked at by a radiologist.
Compression is probably the most talked, joked and feared component of a mammogram. But it is an essential part of the mammogram.
An easy way to imagine what compression does it to imagine a bag of marbles. Each of those marbles represents each of the little parts of your breast that are responsible for making milk. If I placed that bag on a bench and took a photo of it, all I would see is the marbles sitting on the top. But if I placed a clear weight on top of the bag which spread those marbles out, then I could take a picture of all the marbles. This is what compression does. It allows us to image all the parts of the breast without too much overlap.
The result is a clear, crisp image with no blurring that the doctor can use to identify any areas of concern.
For the majority of people compression is uncomfortable at most. I always tell my clients if they experience any pinching or pain to let me know and I can make adjustments. Communication between you and the technician is the key to working together to get the best images possible. We all understand that compression isn’t pleasant but we always work to ensure that it is over quickly.