By Andy Pargulski
DMACC Honors student
My mother had four consecutive mammograms- all interpreted as “normal”- and she actually had breast cancer during every single one of them. Her cancer progressed to stage three before finally being diagnosed. My mom has what is called dense breast tissue, which cloaks cancer in a standard mammogram. Her doctors didn’t inform her that her mammograms might be missing something, and most women believe that when they get a “normal” mammogram result, they think it means that they don’t have cancer. What it really means is that the radiologist couldn’t see cancer, and it is vital to know the difference. Iowa legislators just recently passed Senate File 205, the breast density inform bill, requiring radiologists to inform women their density status and how it impacts mammography, but it is still imperative that Iowans know about their risks.
It is critical for everyone to understand what breast density is, how it impacts mammography, and the additional testing options. Also, people must understand how Senate File 205 impacts this problem. But, before the specifics of the bill, let’s discover what breast density is and how it impacts mammography.
To get a mammogram screening test, the patients primary care physician must order one for the patient first. A typical mammogram is done by having x-ray imaging done to the breasts. It starts by having two plates press down against the breast to provide the clearest image possible. The physician may also make a patient take the mammogram with the machine at a different angle, to get another view of the tissue. This procedure lasts more than 30 minutes.
According to a publication by radiologist Dr. Carrol Lee of Memorial Sloan Kettering titled “What Women Should Know About Density,” 50% of women have dense breast tissue. There are four levels of breast density, according to Dr. Wendie Berg. In an interview, Dr. Berg explains those categories, in ascending order of severity: mostly fatty tissue, scattered fibroglandular tissue, heterogeneously dense tissue, and extremely dense tissue. 40% of women have heterogeneously dense tissue and 10% are considered extremely dense. According to local oncologist Dr. Robert Shreck, this issue impacts roughly 233,000 women in Iowa; most of these women don’t even know that they have this condition. Also, in a research article written by Dr. Thomas Kolb, Dr. Jacob Lichy, and Dr. Jeffery Newhouse titled, “Breast Imaging,” mammographic sensitivity declined significantly with increased breast density. This means, that the denser a woman’s breast is, the less accurate her mammogram is. So much so, in the extremely dense category, that 50% of breast cancers will be missed.
The number one reason cancer is missed in a mammogram is because dense tissue delays the diagnosis. Having dense breast tissue actually puts women at an increased risk. A letter from Dr. Grant Goldsberry, a radiologist at McFarland Clinic, states, “Women with extremely dense breast tissue have a 4-5 fold increased risk of breast cancer.” That means that having extremely dense breast tissue is a greater risk factor for breast cancer than having two sisters with breast cancer. Having dense breast tissue is like a double-edged sword: Not only does it put women at a higher risk for breast cancer, but it also lowers the sensitivity of their mammograms making it harder to detect cancer.
According to the Mayo Clinic there are numerous supplemental screening options. Some of those include 3-D mammography, or breast tomosynthesis, breast MRI, breast ultrasound, and a MBI (Molecular Breast Imaging). As said best again by Dr. Shreck, “We have the worst of all worlds here–a population of women with dense breasts who are more likely to get cancer, and a 50-year-old standard screening procedure that provides a misleading reassurance that things are O.K.”
Now that Iowan legislatures passed Senate File 205, radiologists are required to inform their patients of their density status and risk. This legislation has been introduced to Iowan legislature in 2013, and was finally passed on April 4, 2017. This information would entail that women with increased breast density be informed of that fact, that increased breast density increases the risk of cancer, increased breast density interferes with early detection by mammography, and that each woman should consult with her primary care provider on this issue. Now that women are enabled with this information, this will allow for more informed discussion with a physician about additional screening, testing, and possibly motivate women to decrease breast cancer risk, which can be done by maintaining: healthy weight, limiting alcohol consumption, adhering to a regular exercise schedule, and making healthy dietary decisions. This information could also possibly motivate women to manage their own health better by getting yearly mammograms and being diligent about self-breast examinations.
Senate File 205 was being opposed by the Iowa Medical Society for the following reason: They don’t like legislators mandating their practice. The information about breast density has been known by radiologists for nearly 20 years, yet they are still not sharing it with women. This is why legislators must step in and mandate that the information has to be shared. As stated in the Code of Medical Ethics of the American Medical Association (Section 8.082, Paragraph 2) “Withholding medical information from patients without their consent is ethically unacceptable.” The Iowa Medical Society also wants to wait until standards were established for how to screen women with dense breast tissue. But the Mayo Clinic already has assembled a task force to establish these recommendations, according to Dr. Shreck, and these standards are available to all physicians now. We all have mothers, sisters, aunts and grandmothers who are now, finally, being introduced to this information.
There is an Interest Group, called the Iowa Army of Pink, that heavily advocated for SF 205 in the Iowa Senate. They visited the Iowa state capital building regularly to advocate and lobby for the bill. If you want to get involved with them you could add them on Facebook under the name “Iowa Army of Pink”.
Now that Senate File 205 has been passed into law, radiologists now must share breast density information with women, but the fight is not over. You have been appraised of what breast density is, and what Senate File 205 is, but now you must be aware of what to look for when you or a loved one is getting a breast cancer screening. If you love the women in your life, you have an obligation to know about Senate File 205, and end late stage cancer diagnoses
My mom is now five years in remission and living a happy and healthy life, but there more than enough women who aren’t so lucky. It is imperative to pass SF 205 into law so that we can help end late stage cancer diagnoses.
Andy Pargulski is from Johnston, Iowa, and he is graduating with his Liberal Arts AA in the spring. He plans to transfer to the Ohio State University and double major in Biomedical Science and Sport Psychology. His career goal is to have his own private practice in either medicine or psychology.