Breast Density Notification Research Articles

Why the Federal Breast Density Notification Law Marks a Turning Point for Women’s Health

September 10, 2024, marked a historic shift in women’s healthcare when the first federal breast density notification and reporting mandate went into effect. This means that now, all women in the United States will be informed by their providers about whether they have dense breast tissue after a mammogram. While this law helps to inform women about their risks, it is just the beginning. We need to ensure that women can do something with this important information without facing financial or logistical roadblocks.

Mammographic density in relationships with relevant contributing factors: a multicentric study from Riyadh, Saudi Arabia.

Mammographic breast density (MBD), a well-established factor linked to breast cancer, is the focus of this preliminary report among women across multiple centers in Riyadh. The study aims to identify risk factors associated with high breast density. MBD was assessed at three hospitals in Riyadh, Saudi Arabia, using the American College of Radiology (ACR) categories: A (almost entirely fatty), B (scattered areas of fibroglandular density), C (heterogeneously dense), and D (extremely dense). Breast density distributions were analyzed in relation to age, body mass index (BMI), family history, parity, and hormonal therapy usage. The study included 1,530 women, revealing an inverse association between dense breast proportion and age/BMI. Notably, 43.3% [95% confidence interval (CI): 43.2% to 43.5%] of women aged 40-79 years exhibited heterogeneously or highly dense breasts, with this proportion inversely correlated with age and BMI. Healthcare providers should consider breast density for appropriate screening and, if necessary, recommend supplemental methods. Policymakers and healthcare providers, when discussing breast density notification legislation, should be mindful of its high prevalence, ensuring women notified have opportunities to evaluate breast cancer risk and pursue supplemental screening options if deemed appropriate.

Screening mammography frequency following dense breast notification among a predominantly Hispanic/Latina screening cohort.

Nationally legislated dense breast notification (DBN) informs women of their breast density (BD) and the impact of BD on breast cancer risk and detection, but consequences for screening participation are unclear. We evaluated the association of DBN in New York State (NYS)with subsequent screening mammography in a largely Hispanic/Latina cohort. Women aged 40-60 were surveyed in their preferred language (33% English, 67% Spanish) during screening mammography from 2016 to 2018. We used clinical BD classification from mammography records from 2013 (NYSDBN enactment) through enrollment (baseline) to create a 6-category variable capturing prior and new DBN receipt (sent only after clinically dense mammograms). We used this variable to compare the number of subsequent mammograms (0, 1, ≥ 2) from 10 to 30months after baseline using ordinal logistic regression. In a sample of 728 women (78% foreign-born, 72% Hispanic, 46% high school education or less), first-time screeners and women who received DBN for the first timeafter prior non-dense mammograms had significantly fewer screening mammograms within 30months of baseline (Odds Ratios range: 0.33 (95% Confidence Interval (CI) 0.12-0.85) to 0.38 (95% CI 0.17-0.82)) compared to women with prior mammography but no DBN. There were no differences in subsequent mammogram frequency between women with multiple DBN and those who never received DBN. Findings were consistent across age, language, health literacy, and educationgroups. Women receiving their first DBN after previous non-dense mammograms have lower mammography participation within 2.5years. DBN has limited influence on screening participation of first-time screeners and those with persistent dense mammograms.

Factors Associated with Increased Knowledge about Breast Density in South Australian Women Undergoing Breast Cancer Screening.

Background: There is growing awareness of breast density in women attending breast cancer screening; however, it is unclear whether this awareness is associated with increased knowledge. This study aims to evaluate breast density knowledge among Australian women attending breast cancer screening. Method: This cross-sectional study was conducted on women undergoing breast cancer screening at The Queen Elizabeth Hospital Breast/Endocrine outpatient department. Participants were provided with a questionnaire to assess knowledge, awareness, and desire to know their own breast density. Result: Of the 350 women who participated, 61% were familiar with 'breast density' and 57% had 'some knowledge'. Prior breast density notification (OR = 4.99, 95% CI = 2.76, 9.03; p = 0.004), awareness (OR = 4.05, 95% CI = 2.57, 6.39; p = 0.004), younger age (OR = 0.97, 95% CI = 0.96, 0.99; p = 0.02), and English as the language spoken at home (OR = 3.29, 95% CI = 1.23, 8.77; p = 0.02) were independent predictors of 'some knowledge' of breast density. A significant proportion of participants (82%) expressed desire to ascertain their individual breast density. Conclusions: While knowledge of breast density in this Australian cohort is generally quite low, we have identified factors associated with increased knowledge. Further research is required to determine optimal interventions to increase breast density knowledge.

Abstract IA021: Balancing act: cancer control and equity through implementation and de-implementation

Abstract Promoting evidence-based cancer prevention and control may require de-implementation strategies, aimed at reducing or removing interventions that have been shown as ineffective, potentially harmful, lacking in demonstrated effectiveness, or offering only limited health benefits. De-implementation involves a range of actions, including scaling back these interventions, narrowing their application to specific populations or settings, substituting them with more effective alternatives, or entirely discontinuing them without replacement. The evolving nature of scientific evidence and the shifting landscape of population health priorities, which contribute to changing guidelines over time, make de-implementation an important component of the broader implementation science to advance cancer prevention, control, and equity. While the field is expanding, there remains a research gap in empirical studies that elucidate the factors influencing de-implementation or effective strategies for facilitating it. Emerging data indicate that the drivers of implementation and de-implementation often differ, necessitating distinct or adapted strategies, frameworks, and outcomes. Implementation and de-implementation approaches also have varying implications and considerations for addressing health disparities. Breast cancer screening through mammography serves as a case study, exemplifying an evidence-based practice marked by both underuse and overuse — corresponding to lower and higher guideline-recommended participation, respectively — across different population groups and settings. In this educational session presentation, we will share the approaches and insights gathered from our efforts to promote appropriate screening mammography within racially and ethnically diverse and underserved communities. In this education presentation, we will highlight findings from our NIH-funded studies, focusing on two specific areas: breast density notification and mammography screening in older women. These areas represent current practices characterized by insufficient evidence regarding effectiveness, potential harms, and benefits, along with inconsistent clinical recommendations, illustrating the need for a more deliberate and well-informed approach to enhance breast cancer control and mitigate health disparities. Beyond illuminating some of the challenges at the policy, organizational, and provider levels, we emphasize the critical role that women or patients play in shaping the landscape of breast cancer screening. Their perspectives and experiences are crucial considerations when formulating de-implementation strategies aimed at optimizing breast cancer screening and promoting equity. Citation Format: Parisa Tehranifar, Nathalie Moise, Rachel C. Shelton. Balancing act: cancer control and equity through implementation and de-implementation [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA021.

Implementing the National Dense Breast Reporting Standard, Expanding Supplemental Screening Using Current Guidelines, and the Proposed Find It Early Act.

Thirty-eight states and the District of Columbia (DC) have dense breast notification laws that mandate varying levels of patient notification about breast density after a mammogram, and these cover over 90% of American women. On March 10, 2023, the Food and Drug Administration issued a final rule amending regulations under the Mammography Quality Standards Act for a national dense breast reporting standard for both patient results letters and mammogram reports. Effective September 10, 2024, letters will be required to tell a woman her breasts are "dense" or "not dense," that dense tissue makes it harder to find cancers on a mammogram, and that it increases the risk of developing cancer. Women with dense breasts will also be told that other imaging tests in addition to a mammogram may help find cancers. The specific density category can be added (eg, if mandated by a state "inform" law). Reports to providers must include the Breast Imaging Reporting and Data System density category. Implementing appropriate supplemental screening should be based on patient risk for missed breast cancer on mammography; such assessment should include consideration of breast density and other risk factors. This article discusses strategies for implementation. Currently 21 states and DC have varying insurance laws for supplemental breast imaging; in addition, Oklahoma requires coverage for diagnostic breast imaging. A federal insurance bill, the Find It Early Act, has been introduced that would ensure no-cost screening and diagnostic imaging for women with dense breasts or at increased risk and close loopholes in state laws.

Abstract P6-05-38: Breast Density Notification: Impact on anxiety, breast cancer worry, and self-perceived risk among Latinas at a federally qualified medical center

Abstract Mammographic breast density (MBD) has been shown to be a strong, independent risk factor for breast cancer (BC) irrespective of race/ethnicity. Given the risk association of MBD and its potential to mask tumors on a mammogram, state and federal laws have mandated that women receive information regarding their personal MBD in their mammography reports. However, concerns have been raised regarding the impact of MBD notification on patient anxiety, especially written information for women who experience health disparities such as racial/ethnic minorities, lower health literacy, limited English proficiency and lower socioeconomic status. We performed a randomized controlled clinical trial to examine the impact of three different written and interpersonal approaches to MBD notification on patient anxiety, BC worry, and self-perceived BC risk, among Latinas receiving routine mammography screening at a federally qualified medical center (FQHC). We hypothesized that interpersonal education would reduce anxiety and worry, relative to the written notifications alone. The study was performed at the Baseline Clinic of Mountain Park Health Center, a FQHC in Phoenix, AZ. Women between ages 40 and 74 years presenting for screening mammogram were eligible. After providing signed informed consent, participants were randomized equally to usual care (UC- mailed notification letter); enhanced care (notification letter and MBD educational brochure designed for this study): interpersonal care (notification letter, brochure, promotora education via telephone). A stratified block randomization procedure was used with age > 50 years (yes vs no), ethnicity (Hispanic vs non-Hispanic), and language preference (Spanish vs. English) as strata. Study participants completed surveys at the time of enrollment/pre-intervention (T0), at two weeks to six months after intervention was delivered (T1), and about one year after randomization (T2). Anxiety state was measured using the state anxiety subscale of the State-Trait Anxiety Inventory scale (STAI-S) (range from 20-80). BC worry was probed using the question: “How frequently do you worry about getting breast cancer someday”. The self-perceived lifetime risk of BC was rated between 0% (no chance of BC) to 100% (definitely will get BC). The proportion of participants with an increase or persistence of higher level for each outcome between time points was compared between the three study groups. The study was approved by the Mayo Clinic Institutional Review Board. 1332 Latina women were enrolled and randomized between October 2016 and October 2019. All completed the baseline (T0) survey, 928 completed T1, 632 completed T2, and 516 completed both T1 and T2 surveys. At study entry, majority of the participants were young (64.1% between age 40-49 years), had no family history of breast cancer (81.0%), had less than high school education (68.8%), and were married or partnered (67.8%). At T0, the mean (SD) anxiety STAI score was 32.5 (11.1); 51.8% with moderate or severe anxiety (score > 30). With regard to BC worry, 41.3% reported worrying “sometimes”, “often”, or “almost all the time”. Further, 25.4% reported a self-perceived lifetime risk of developing BC of >10% while only 6.6% had a Gail model estimated lifetime risk score of >10%. There was no significant difference in changes in anxiety, BC worry or self-perceived risk from T0 to either T1 or T2 surveys between the intervention groups. In summary, this study found high levels of baseline anxiety and BC worry (despite the majority being 40-49 years old and having no family history of BC) which persisted regardless of how notification and education were delivered. Future work is needed to improve the understanding of factors that could lower anxiety and BC worry and improve risk perception in this population. Citation Format: Karthik Ghosh, Sarah Jenkins, Jennifer Ridgeway, Jessica D. Austin, Bijan Borah, Bhavika K. Patel, Deborah Rhodes, Aaron Norman, Edna P. Ramos, Matt Jewett, Crystal Gonzalez, Valentina Hernandez, Davinder Singh, Vera Suman, Celine Vachon. Breast Density Notification: Impact on anxiety, breast cancer worry, and self-perceived risk among Latinas at a federally qualified medical center. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-38.

Abstract P5-04-08: Breast cancer screening using ultrasound increases recall, biopsy, and cancer detection rates

Abstract Background: Ultrasound is often used as an adjunct to mammography for breast cancer (BC) screening. Usage of screening ultrasound (US) varies by state, likely due to differences in state-specific breast density notification laws and mandates requiring insurance coverage of supplemental screening for women at elevated risk of breast cancer. Screening US can increase cancer detection rates among women with dense breasts, but may increase recalls and benign biopsies. As more states adopt policies mandating insurance coverage for “medically necessary” breast cancer imaging, it is important to understand the impact to screening US utilization and subsequent service utilization. This analysis examines use of screening US by state as well as associated rates of recall, biopsy, and cancer detection. Methods: We analyzed deidentified administrative claims. We included women aged 18-74 years with ≥1 claim for screening mammography in 2018. First claim was index date. Continuous enrollment was required in a commercial (COM) or Medicare Advantage (MA) plan from 1/2016 to index date (baseline period) and from index date to 6 months after (follow-up period). Recall, biopsy, and cancer detection rates were calculated for the follow-up period. Recall was defined as ≥1 claim for mammography, diagnostic ultrasound, or MRI in the follow-up period. We used CPT/HCPCS codes to identify procedures. Screening US was identified by CPT 76641 (complete) with modifier 50 (bilateral) or LT/RT (left/right). Using ICD codes, cancer detection was defined as ≥1 claim for DCIS or invasive BC. We examined screening US rates by insurance type, state, and age. Proportions were compared with chi-squared tests. Results: 939,410 women met study criteria (70% COM, 30% MA; Tables 1-2). In the COM population, recall, biopsy, and cancer detection rates with screening US were approximately two-fold higher than without (recall: 26.1% vs. 11.8%; biopsy: 5.0% vs 1.6%; cancer detection: 1.0% vs. 0.4%). In the MA population, recall, biopsy, and cancer detection rates with screening US were roughly three-fold higher than without (recall: 23.6% vs 9.0%; biopsy: 5.2% vs 1.6%; cancer detection: 1.9% vs 0.7%). In NY, NJ, and CT, the rate of screening US usage was > 14 times higher than in all other states (29.1% vs 1.9%). These three states had higher recall and biopsy rates, but similar cancer detection rates compared to all other states (recall: 14.4% vs. 11.4%; biopsy: 2.5% vs 1.7%; cancer detection: 0.6% vs. 0.5%). All proportion differences reached statistical significance (p < 0.001). Conclusion: Screening US was associated with increases in recall and biopsy, but modest increases in absolute cancer detection rates. Observed state by state variation of screening US is likely driven by laws requiring zero patient payment insurance coverage of “medically necessary” imaging which, as is the case with NY, NJ, and CT, is interpreted to include screening US. Our results demonstrate that screening US may lead to a large increase in recall rates and biopsies without consequentially improving the cancer detection rate. Table 1: Recall, biopsy, and cancer detection rates by age with and without use of adjunctive breast screening ultrasound in a commercially insured U.S. population * values are suppressed to comply with requirements for data release Table 2: Recall, biopsy, and cancer detection rates by age with and without use of adjunctive breast screening ultrasound in a Medicare Advantage (MA) U.S. population * values are suppressed to comply with requirements for data release Citation Format: James Staib, Rashna Soonavala, Stacey Dacosta Byfield, Kimberly Badal, Kierstin Catlett, Liz Maffey, Mi-Ok Kim, Kenneth Wimmer, Yiwey Shieh, Laura J. Esserman. Breast cancer screening using ultrasound increases recall, biopsy, and cancer detection rates [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-04-08.

Australian Women's Responses to Breast Density Information: A Content Analysis.

Content analysis was used to assess responses from a written questionnaire undertaken in conjunction with focus groups on BD involving 78 Australian women aged 40-74. Half the women reported that they would feel a little anxious if notified they had dense breasts, while 29.5% would not feel anxious. The most common theme (29.5%) related to anxiety was the psychosocial impact of the possibility of developing cancer, and women believed that being better informed could help with anxiety (26.9%). When asked what they would do if notified of having dense breasts, the most common response was to consult their doctor for information/advice (38.5%), followed by considering supplemental screening (23%). Consequently, when asked directly, 65.4% were interested in undergoing supplemental screening, while others (10.3%) said they "wouldn't worry about it too much". These findings have important implications for health systems with population-based breast screening programs that are currently considering widespread BD notification in terms of the impact on women, health services and primary care.

Abstract B011: Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort vary by educational attainment and dominant language

Abstract Introduction: Socioeconomic, racial and ethnic disparities in the awareness and knowledge of dense breast notification (DBN) legislation have been documented, but its effect on women’s cognitive and emotional appraisal of the notification information which affect screening behavior remains unknown. Ambiguous screening and follow-up care for women with dense breasts may allow DBN to increase women’s anxiety, perceptions of risk, and worry, with unclear consequences for future screening decisions. We examined short- and long-term psychological responses to DBN and awareness of breast density (BD) by education, health literacy, nativity and dominant language. Methods: In a predominantly Latina and foreign-born New York City screening cohort (63% Spanish-speaking), ages 40-60, we assessed breast cancer worry, perceived absolute and comparative breast cancer risk, and uncertainties about breast cancer risk and screening choices, in short (approximately 1-3 months) and long-term (approximately 9-18 months) surveys following the enrollment screening mammogram (between 2016-2018). We compared psychological responses by women’s dense breast status (as proxy for DBN receipt) and BD awareness using cumulative, binary, and multinomial logistic regression. We examined multiplicative interaction by education, health literacy, nativity, and interview language. Results: In multivariable models using short-term surveys, BD awareness was associated with increased absolute perceived risk (Odds Ratio (OR): 2.27, 95% Confidence Interval (CI): 0.99, 5.20 for high, OR: 2.19, 95% CI: 1.34, 3.58 for moderate, vs. low risk) in the overall sample, and with increased uncertainty about risk (OR: 1.97 per 1-unit increase, 95% CI: 1.15, 3.39) and uncertainty about screening choices (OR: 1.73 per 1-unit increase, 95% CI: 1.01, 2.9) in women who are Spanish-dominant. DBN was associated with decreased perceived risk among women with at least some college education (OR: 0.32, 95% CI: 0.11, 0.89, for high, OR: 0.50, 95% CI 0.29, 0.89, for moderate vs. low risk) while those with a high school education or less experienced an increase (OR: 3.01, 95% CI: 1.05, 8.67 high vs. low risk). There were no associations observed between DBN or BD awareness and short-term breast cancer worry, nor with any psychological outcomes at long-term surveys. Conclusions: Associations of BD awareness and notification with breast cancer related psychological outcomes differed by education and language and were limited to short term increases in perceived absolute breast cancer risk and uncertainty around breast cancer risk and screening choices. Women with lower educational attainment or language barriers could specifically benefit from outreach to clarify the implications of breast density and reduce uncertainty around risk and screening choices. Citation Format: Erica J. Lee Argov, Carmen B. Rodriguez, Mariangela Agovino, Ying Wei, Rachel C. Shelton, Rita Kukafka, Karen M. Schmitt, Elise Desperito, Mary Beth Terry, Parisa Tehranifar. Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort vary by educational attainment and dominant language [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B011.

Understanding of Dense Breast and Perception of Breast Cancer Risk of Nurses with or without Dense Breast Notification

Understanding of Dense Breast and Perception of Breast Cancer Risk of Nurses with or without Dense Breast Notification

Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort

BackgroundDense breast notification (DBN) legislation aims to increase a woman’s awareness of her personal breast density and the implications of having dense breasts for breast cancer detection and risk. This information may adversely affect women’s breast cancer worry, perceptions of risk, and uncertainty about screening, which may persist over time or vary by sociodemographic factors. We examined short- and long-term psychological responses to DBN and awareness of breast density (BD).MethodsIn a predominantly Hispanic New York City screening cohort (63% Spanish-speaking), ages 40–60 years, we assessed breast cancer worry, perceived breast cancer risk, and uncertainties about breast cancer risk and screening choices, in short (1–3 months)- and long-term (9–18 months) surveys following the enrollment screening mammogram (between 2016 and 2018). We compared psychological responses by women’s dense breast status (as a proxy for DBN receipt) and BD awareness and examined multiplicative interaction by education, health literacy, nativity, and preferred interview language.ResultsIn multivariable models using short-term surveys, BD awareness was associated with increased perceived risk (odds ratio (OR) 2.27, 95% confidence interval (CI) 0.99, 5.20 for high, OR 2.19, 95% CI 1.34, 3.58 for moderate, vs. low risk) in the overall sample, and with increased uncertainty about risk (OR 1.97 per 1-unit increase, 95% CI 1.15, 3.39) and uncertainty about screening choices (OR 1.73 per 1-unit increase, 95% CI 1.01, 2.9) in Spanish-speaking women. DBN was associated with decreased perceived risk among women with at least some college education (OR 0.32, 95% CI 0.11, 0.89, for high, OR 0.50, 95% CI 0.29, 0.89, for moderate vs. low risk), while those with a high school education or less experienced an increase (OR 3.01, 95% CI 1.05, 8.67 high vs. low risk). There were no associations observed between DBN or BD awareness and short-term breast cancer worry, nor with any psychological outcomes at long-term surveys.ConclusionsAssociations of BD awareness and notification with breast cancer-related psychological outcomes were limited to short-term increases in perceived breast cancer risk dependent on educational attainment, and increases in uncertainty around breast cancer risk and screening choices among Spanish-speaking women.

Factors associated with women's supplemental screening intentions following dense breast notification in an online randomised experimental study.

Controversy surrounding recommendations for supplemental screening (ultrasound and magnetic resonance screening) in women with dense breasts exists, as the long-term benefits from these additional modalities may not outweigh the harms. This study aimed to examine factors associated with supplemental screening intentions following a hypothetical breast density notification in a population of women who have not been routinely notified. Australian women of breast screening age participated in an online randomised experimental study where they were presented with one of two breast density notifications (with or without health literacy-sensitive information) and asked their screening intentions. After adjusting for covariates in multivariable analyses, women in both groups (n = 940) who indicated higher levels of breast cancer worry, had private health insurance, had a family history of breast cancer, and had a greater number of times previously attending mammography screening had higher intentions for supplemental screening. Understanding women's supplemental screening intentions following notification of dense breasts has important implications for health systems with breast screening considering the impacts of widespread notification. Personal, clinical and psychological factors should be considered when discussing both the benefits and harms of supplemental screening with women with dense breasts.

Investigating the effectiveness of supplemental breast cancer screening tests considering radiologists’ bias

Breast density is known to increase breast cancer risk and decrease mammography screening sensitivity. Breast density notification laws require physicians to inform women with high breast density of these potential risks. The laws usually require healthcare providers to notify patients of the possibility of using more sensitive supplemental screening tests (i.e., ultrasound and MRI). Since the enactment of the laws, there have been controversial debates over (i) their implementations due to the potential radiologists’ bias in breast density classification of mammogram images and (ii) the necessity of supplemental screenings for all patients with high breast density. In this study, we formulate a finite-horizon, discrete-time partially observable Markov chain to investigate the effectiveness of supplemental screening and the impact of radiologists’ misclassification bias on patients’ outcomes. We consider the conditional probability of eventually detecting breast cancer in early states given that the patient develops breast cancer in her lifetime as the primary and the expected number of supplemental tests as the secondary patient’s outcome. Our results indicate that referring patients to a supplemental test solely based on their breast density may not necessarily improve their health outcomes and other risk factors need to be considered when making such referrals. Additionally, average-skilled radiologists’ performances are shown to be comparable with the performance of a perfect radiologist (i.e., 100% accuracy in breast density classification). However, a significant bias in breast density classification (i.e., consistent upgrading or downgrading of breast density classes) can negatively impact a patient’s health outcomes.

Australian General Practitioners' Current Knowledge, Understanding, and Feelings Regarding Breast Density Information and Notification: A Cross-Sectional Study.

Background: There is a lack of evidence around Australian general practitioners’ (GPs) views of issues surrounding breast density. The current study aimed to quantitatively assess GPs’ current knowledge, understanding, and feelings around breast density information and notification. Methods: This study involved a cross-sectional survey using an online platform to collect quantitative data from Australian GPs. Survey data were analysed with descriptive statistics. Results: A total 60 responses from GPs were analysed. Most (n = 58; 97%) had heard or read about breast density and nearly 90% (n = 52; 87%) have had discussions about breast density with patients. Three-quarters (n = 45; 75%) were supportive of making breast density notification mandatory for patients with dense tissue and a similar proportion (n = 45/58; 78%) felt they need or want more education on breast density. Conclusions: There is strong support for notifying patients of breast density, and interest in further education and training among the surveyed GPs. As GPs play a central role in cancer prevention and control, their involvement in discussions related to breast density notification, evaluation and appraisal of evidence, development of communication strategies, and participation in ongoing research on the topic will be indispensable.

Breast Density Legislation Impact on Breast Cancer Screening and Risk Assessment.

To evaluate breast density notification legislation (BDNL) on breast imaging practice patterns, risk assessment, and supplemental screening. A 20-question anonymous web-based survey was administered to practicing Society of Breast Imaging radiologists in the U.S. between February and April 2021 regarding breast cancer risk assessment, supplemental screening, and density measurements. Results were compared between facilities with and without BDNL using the two-sided Fisher's exact test. One hundred and ninety-seven radiologists from 41 U.S. states, with (187/197, 95%) or without (10/197, 5%) BDNL, responded. Fifty-seven percent (113/197) performed breast cancer risk assessment, and 93% (183/197) offered supplemental screening for women with dense breasts. Between facilities with or without BDNL, there was no significant difference in whether risk assessment was (P = 0.19) or was not performed (P = 0.20). There was no significant difference in supplemental screening types (P > 0.05) between BDNL and non-BDNL facilities. Thirty-five percent (69/197) of facilities offered no supplemental screening studies, and 25% (49/197) had no future plans to offer supplemental screening. A statistically significant greater proportion of non-BDNL facilities offered no supplemental screening (P < 0.03) and had no plans to offer supplemental screening compared to BDNL facilities (P < 0.02). Facilities in BDNL states often offer supplemental screening compared to facilities in non-BDNL states. Compared to BDNL facilities, a statistically significant proportion of non-BDNL facilities had no supplemental screening nor plans for implementation. Our data suggest that upcoming federal BDNL will impact how supplemental screening is addressed in currently non-BDNL states.

Australian Women’s Intentions and Psychological Outcomes Related to Breast Density Notification and Information

Whether the benefits of notifying women about breast density outweigh the potential harms to inform current and future mammogram screening practice remains unknown. To assess the effect of mammographic breast density notification and information provision on women's intention to seek supplemental screening and psychological outcomes. A 3-arm online randomized clinical trial was conducted from August 10 to 31, 2021. Data analysis was conducted from September 1 to October 20, 2021. Participants included Australian residents identifying as female, aged between 40 and 74 years, with no history of breast cancer who were residing in jurisdictions without existing breast density notification with screening mammograms. Women were randomized to receive 1 of the following hypothetical breast screening test result letters: screening mammogram result letter without breast density messaging (control), screening mammogram result letter with breast density messaging and an existing density information letter taken from a screening service in Australia (intervention 1), and screening mammogram result letter with breast density messaging and a health literacy-sensitive version of the letter adapted for people with lower health literacy (intervention 2). Primary outcomes were intention to seek supplemental screening; feeling anxious (uneasy, worried, or nervous), informed, or confused; and having breast cancer worry. A total of 1420 Australian women were randomized and included in the final analysis. The largest group consisted of 603 women aged 60 to 74 years (42.5%). Compared with the control cohort (n = 480), women who received density notification via intervention 1 (n = 470) and intervention 2 (n = 470) reported a significantly higher intention to seek supplemental screening (0.8% vs 15.6% and 14.2%; P < .001) and feeling anxious (14.2% vs 49.4% and 48.5%; P < .001), confusion (7.8% vs 24.0% and 23.6%; P < .001), and worry about breast cancer (quite/very worried: 6.9% vs 17.2% and 15.5%; P < .001). There were no statistically significant differences in these outcomes between the 2 intervention groups. In this randomized clinical trial, breast density notification and information integrated with screening mammogram results increased women's intention to seek supplemental screening and made women feel anxious, confused, or worried about breast cancer. These findings have relevance and implications for mammogram screening services and policy makers considering whether and, if so, how best to implement widespread notification of breast density as part of mammography screening. ACTRN12621000253808.

Association Between Lifestyle Changes, Mammographic Breast Density, and Breast Cancer.

In screening for breast cancer (BC), mammographic breast density (MBD) is a powerful risk factor that increases breast carcinogenesis and synergistically reduces the sensitivity of mammography. It also reduces specificity of lesion identification, leading to recalls, additional testing, and delayed and later-stage diagnoses, which result in increased health care costs. These findings provide the foundation for dense breast notification laws and lead to the increase in patient and provider interest in MBD. However, unlike other risk factors for BC, MBD is dynamic through a woman’s lifetime and is modifiable. Although MBD is known to change as a result of factors such as reproductive history and hormonal status, few conclusions have been reached for lifestyle factors such as alcohol, diet, physical activity, smoking, body mass index (BMI), and some commonly used medications. Our review examines the emerging evidence for the association of modifiable factors on MBD and the influence of MBD on BC risk. There are clear associations between alcohol use and menopausal hormone therapy and increased MBD. Physical activity and the Mediterranean diet lower the risk of BC without significant effect on MBD. Although high BMI and smoking are known risk factors for BC, they have been found to decrease MBD. The influence of several other factors, including caffeine intake, nonhormonal medications, and vitamins, on MBD is unclear. We recommend counseling patients on these modifiable risk factors and using this knowledge to help with informed decision making for tailored BC prevention strategies.

The impact of breast density notification on rescreening rates within a population-based mammographic screening program

BackgroundHigh participation in mammographic screening is essential for its effectiveness to detect breast cancers early and thereby, improve breast cancer outcomes. Breast density is a strong predictor of breast cancer risk and significantly reduces the sensitivity of mammography to detect the disease. There are increasing mandates for routine breast density notification within mammographic screening programs. It is unknown if breast density notification impacts the likelihood of women returning to screening when next due (i.e. rescreening rates). This study investigates the association between breast density notification and rescreening rates using individual-level data from BreastScreen Western Australia (WA), a population-based mammographic screening program.MethodsWe examined 981,705 screening events from 311,656 women aged 40+ who attended BreastScreen WA between 2008 and 2017. Mixed effect logistic regression was used to investigate the association between rescreening and breast density notification status.ResultsResults were stratified by age (younger, targeted, older) and screening round (first, second, third+). Targeted women screening for the first time were more likely to return to screening if notified as having dense breasts (Percentunadjusted notified vs. not-notified: 57.8% vs. 56.1%; Padjusted = 0.016). Younger women were less likely to rescreen if notified, regardless of screening round (all P < 0.001). There was no association between notification and rescreening in older women (all P > 0.72).ConclusionsBreast density notification does not deter women in the targeted age range from rescreening but could potentially deter younger women from rescreening. These results suggest that all breast density notification messaging should include information regarding the importance of regular mammographic screening to manage breast cancer risk, particularly for younger women. These results will directly inform BreastScreen programs in Australia as well as other population-based screening providers outside Australia who notify women about breast density or are considering implementing breast density notification.

Association Between Dense Breast Legislation and Cancer Stage at Diagnosis

Many states have mandated breast density notification and insurance coverage for additional screening; yet, the association between such legislation and stage of diagnosis for breast cancer is unclear. This study investigates this association and examines the differential impacts among different age and race/ethnicity subgroups. The Surveillance, Epidemiology, and End Results database was queried to identify patients with breast cancer aged 40-74 years diagnosed between 2005 and 2016. Using a difference-in-differences multinomial logistic model, the odds of being diagnosed at different stages of cancer relative to the localized stage depending on legislation and individual characteristics were examined. Analyses were conducted in 2020-2021. The study included 689,641 cases. Overall, the impact of notification legislation was not significant, whereas insurance coverage legislation was associated with 6% lower odds (OR=0.94, 95% CI=0.91, 0.96) of being diagnosed at the regional stage. The association between insurance coverage legislation and stage of diagnosis was even stronger among women aged 40-49 years, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.96) of being diagnosed at the regional stage and 12% lower odds (OR=0.88, 95% CI=0.81, 0.96) of being diagnosed at the distant stage. Hispanic women benefited from notification laws, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.97) of being diagnosed at distant stage. Neither notification nor supplemental screening insurance coverage legislation showed a substantial impact on Black women. The findings imply that improving insurance coverage is more important than being notified overall. Raising awareness is important among Hispanic women; improving communication about dense breasts and access to screening might be more important than legislation among Black women.