Kudos to the Los Angeles Times for its story, “California doctors must soon tell women if they have dense breasts.” Excerpts:
Doctors in California will soon have to tell a patient if a mammogram reveals she has dense breasts. They will have to explain that breast density is associated with a higher risk of breast cancer, that it makes mammograms harder to read and that “a range of screening options are available.”
The new law, which will go into effect April 1, 2013, follows similar ones that have passed in Connecticut, Texas, Virginia and New York. It is endorsed by a variety of groups, including the California Radiological Society, the California Nurses Assn., California affiliates for the Susan G. Komen Foundation and Planned Parenthood Affiliates of California. Sponsored by California State Sen. Joe Simitian (D-Palo Alto), it was recently signed by Gov. Jerry Brown.
But other specialists worry about laws that require notification about dense breasts. Many don’t think that more screening and more testing is necessarily what women need in the fight against breast cancer.
In an article published in Radiology Today in August, specialists voiced concerns that such laws “may complicate women’s screening decisions, lead to confusion about screening follow-up, increase the potential for false-positives, and create additional healthcare costs.” The article notes that breast density scores can vary in different specialists’ hands, and that alternative methods of screening (ultrasound and MRI) may lead to more false-positives — resulting in unnecessary tests — and may not be covered by a woman’s health insurance.
Here’s what breast doctor Susan Love (of the Dr. Susan Love Research Foundation) has to say about the breast density issue (and the new law) on her blog. She notes that the issue of breast cancer diagnosis and breast cancer death are turning to not be the same thing. She cites a six-year study published in the Journal of the National Cancer Institute earlier this year that found women with dense breasts are no more likely to die from breast cancer than those whose breasts are not dense. In fact, the greatest risk of death in that study was for women whose tumors were large and in women with fatty breasts.
“Could it be that dense tissue represents a local microenvironment that promotes cancer development, but not spread? Or that the low breast density seen in obese women creates a microenvironment that makes tumors more aggressive? That is something we need to study. … Maybe dense breast tissue increases the risk of getting cancer, but not dying of it. If this is true, it might mean we don’t need to treat the tumors of all women with dense breast tissue the same way, or the same as we would a woman with fatty breasts.”
And this: “It’s especially important to think about these findings in the context of the mammography debates and the push for breast density legislation. All too often, a recommendation like the one the US Preventive Services Task Force made for routine mammography screening to begin at age 50 is interpreted as a conspiracy to cut healthcare costs that will ultimately increase breast cancer deaths. Or, we look to legislation, like the laws we’ve seen about breast density, as a way to get women more screening — even though there is no evidence that more screening is better.”
And, in a separate blog post, the Times offered 3 different expert opinions on the issue. You can read all three, but here’s what Dr. Otis Brawley of the American Cancer Society says:
“I am concerned when people try to legislate the practice of medicine,” Brawley said. And he has other problems with this law. One is the fact that breast density scores are not yet precise: “One radiologist‘s eyes may be very different from another radiologist’s eyes at this point,” he says.
But the biggest problem, he adds, “is if I have a patient with dense breasts, I am not sure at this juncture what is the right thing to do with that woman.”
Brawley believes that doctors should be frank with their patients. But he thinks the legislation is likely to result in increased numbers of women being referred for additional tests, and this may not necessarily be helpful. “More screening is more radiation, which is actually for sure going to cause more cancer,” he says, “and it’s for sure going to cause more women to have false positives and get fed up with screening and say, No more screening for me.'” He says there already is a problem with women in their 40s having false positives and swearing off screening so that by the time they reach their 50s, when breast cancer screening is more important, some are avoiding the tests.
Brawley adds that some data suggest that the types of breast cancer that women with dense breasts get may be less dangerous. This may sound odd, but scientists now know that that not all breast cancer is the same and that maybe 15%-20% of the breast tumors women get are localized ones that are not going to progress, he says.
“All of these things basically create a situation where we do not know exactly the right thing to do,” he said. “And whenever we don’t know what the right thing to do is, it frightens me when you legislate what people should do.”
This is the kind of health care journalism we should praise and support – especially in contrast with some of what we’ve commented on in this blog just in the past two days.