By Sue Sveum
Most women know that when it comes to breast cancer, early detection saves lives. But what you may not know is that a mammogram isn’t always enough — especially for women with dense breast tissue. But what are dense breasts, and how do you know if you have them?
“It refers to a higher ratio of fibrous and glandular tissue to fatty,” explains Dr. Jennifer Bergin, partner at Radiology Waukesha and medical director of breast imaging services at ProHealth Care. “Unfortunately, dense tissue and cancer both appear white on a mammogram, possibly masking tumors in dense breasts.”
“A lot of women aren’t aware of this issue,” adds Erin Fabrizius, government relations liaison for the Wisconsin Radiological Society. “Dense breasts are both normal and common, so that’s nothing to be alarmed about. It just means that traditional mammography screening may not be enough.”
In fact, every major medical organization issuing breast cancer screening guidelines for high-risk women now recommend supplemental screening by MRI. Risk factors for women include: “age, family history, genetic mutations and dense breast tissue. Women with a cumulative lifetime risk of breast risk greater than 20% are considered high risk,” according to the Wisconsin Radiological Society.
In 2018, a Wisconsin state law was enacted requiring patients to be notified by their doctor if they have dense breast tissue. But many experts say that’s not enough — because Wisconsin insurance companies aren’t currently required to cover supplemental screening (ultrasound or MRI) for women with dense breasts or those who are high-risk.
Legislation introduced during the 2023-24 Wisconsin State Legislative Session, titled Assembly Bill 117 and Senate Bill 121, aims to change that — making it easier for high- risk women and those with dense breasts to obtain additional imaging without paying for it out of pocket (see sidebar).
Nancy Thorne Cahill remembers when 3D mammography wasn’t even covered in 2002, when she was diagnosed with breast cancer.
“I had to pay [for a 3D mammogram],” she says. “But if something doesn’t seem right, get more testing.”
Just ask Linda Hansen. A 14-year breast cancer survivor, Hansen says her yearly mammograms always came back clear. And when she first learned she had dense breasts, her doctor said it was nothing to worry about.
Shortly after another clear mammogram, she felt a twinge of pain in her right breast while running, and also noticed a dent in her breast. Her OB/GYN ordered an MRI, but when she showed up for her appointment, she was informed that her insurance company denied authorization of the $5,000 scan claim. Based on the denial, the hospital refused to do the MRI.
Her insurance company ultimately covered it — and the MRI found what her mammogram missed.
“I had stage 4 metastatic breast cancer, with a life expectancy of 18 to 24 months,” Hansen recalls. “I was stunned.”
She later learned that finding breast cancer in dense breasts with a mammogram is what she describes as akin to finding “a snowflake in a snowball — nearly impossible.”
“The outlook wasn’t good, but I knew I wanted to fight as long as possible,” Hansen says. And she has — not only for herself, but as an advocate for other women with breast cancer. “When I heard of someone living five years with my diagnosis, a raincloud lifted and I thought, ‘I could do that!’”
Treatment included numerous surgeries and weeks of radiation. Hansen still does chemotherapy every three weeks, and says she will probably have to the rest of her life.
“I want this to mean something to other people,” she says. “If my story can save even one life, it’s worth telling.”
Ashley Inda understands. At just 35 years old, she felt a lump in her breast. When she went in for imaging, her mammogram and ultrasound both came back clear. As the lump grew, Inda was told it was “just dense tissue.” But, according to the National Cancer Institute, it’s impossible to see or feel dense tissue — it’s identifiable only on a mammogram. Two and a half years later, Inda was diagnosed with breast cancer at 38 years old. Inda wishes she would have pushed for an MRI after the lump kept growing.
An early MRI might’ve diagnosed her cancer at stage 1. Instead, her cancer was caught at stage 3, and it had it spread to her lymph nodes, leading to a bilateral mastectomy, chemotherapy, radiation, immunotherapy and oral chemo.
“I feel strongly that women need to be their own advocates — especially when it comes to dense breasts,” Inda says, urging readers to visit mydensitymatters.org to learn more. “If your doctor doesn’t suggest supplemental screening, ask for it.”
Fabrizius agrees, adding that as many as 50% of women have dense breasts — making them four to six times more likely to get breast cancer.
“It’s also important to know your lifetime risk of breast cancer,” she says. “By age 25, ask your provider about risk assessment (see sidebar) — so you’ll know before age 40 if you’d benefit from starting breast cancer screening exams earlier.”
Dr. Bergin says that regardless of age, women should practice “breast awareness” — knowing how your breasts look and feel — and note any changes. Mention any differences to your doctor, so they can recommend what to do next.
“People are finally starting to take dense breasts seriously. But now we need lawmakers to pass this bill,” says Hansen. “It’s a matter of life and death — literally.”
What is My Risk for Breast Cancer?
Although age 40 is the standard for a first mammogram, women should know their lifetime risk by age 25 of developing breast cancer.
Women with a lifetime risk greater than 20% are advised to begin mammograms — and possibly other imaging — sooner. (Dr. Jennifer Bergin, partner at Radiology Waukesha and medical director of breast imaging services at ProHealth Care, notes that there are personalized factors that contribute to screening recommendations, so talk to your doctor.)
“One commonly-used risk model you can access is the Tyrer-Cuzick version 8 risk calculator (ibis-risk-calculator.magview.com),” she says. “[However], it’s not intended for women who’ve already had breast cancer since the data can’t accurately estimate risk for a second cancer. Of course, it’s not a substitute for medical advice — so follow up with your provider for a more in-depth and personalized conversation.”
Screening Recommendations and 2023 Assembly Bill 117/ Senate Bill 121
The facts:
- As many as 50% of women have dense breasts, making them four to six times
- more likely to develop breast cancer. Mammograms miss nearly 50% of tumors in extremely dense breasts. Ultrasounds miss 40%.
- MRI is the recommended method of supplemental screening for high-risk women.
- Wisconsin health insurers are currently not required to pay for additional screening.
- Out-of-pocket costs for supplemental imaging can range from $234 to more than $1,000 — making it prohibitive for many.
- An early breast cancer diagnosis can reduce treatment costs by two to four times, compared to a late-stage diagnosis.
- Therefore, early detection by any method of screening leads to better outcomes for patients and reduces costs for patients and insurers alike.
Bill basics:
- 2023 Assembly Bill 117 and Senate Bill 121, introduced in the Wisconsin Legislature, would require health insurers to cover supplemental or diagnostic breast screening examinations (MRI or ultrasound) for high-risk women or those with dense breast tissue.
- States with similar legislation estimate insurance costs to increase by just four to seven cents per member per month (48 to 84 cents annually).
- The bipartisan bill, which has been introduced in two consecutive state legislative sessions, is gaining support, and will be reintroduced in January 2025.
How you can help:
Contact your legislators (search here: legis.wisconsin.gov) or the Early Detection Saves Lives Coalition (earlydetectionwi.com) to express your support and encourage lawmakers to support access to life-saving breast imaging.
