Why Breast Density Matters When It Comes to Breast Cancer Screening

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Story at-a-glance -

  • "Happygram” reveals the oft-ignored side of breast cancer screening with mammography — the fact that more often than not, it fails to identify cancer in women with dense breast tissue
  • 49 percent of women have high breast tissue density, and nearly 75 percent of dense-breasted women are at risk for a cancer being missed if they rely solely on mammography
  • Dense-breasted women are also up to six times more likely to develop breast cancer than women with less dense breasts

By Dr. Mercola

An annual mammogram is the conventional go-to "prevention" strategy for breast cancer. But, researchers increasingly agree that mammography is ineffective at best, and harmful at worst.

Unfortunately, breast cancer is big business, and mammography is one of its primary profit centers. This is why the industry is so reluctant to admit its many flaws and dangers.

The featured documentary, "Happygram," reveals the oft-ignored side of breast cancer screening with mammography — the fact that more often than not, it fails to identify cancer in women with dense breast tissue.

I've written many articles on the hazards and drawbacks of mammograms, including the risks of false positives, and the facts that ionizing radiation causes cancer, and that mammograms have no impact on mortality rates.

In this article, I will focus on the risks associated with false negatives, meaning you have cancer but the mammogram fails to show it, and who's at greatest risk for receiving a misleading "Happygram."

For Dense-Breasted Women, the 'Happygram' Is Often Wrong

"Happygram" is a term used to describe the form letter women receive stating that their mammograms are "normal." Alas, for thousands of women with dense breasts, their Happygram turned out to be anything but.

The producer of this film, Julie Marron, conceived the idea of making a documentary on mammography's failings after her friend, New York writer Hallie Leighton, was diagnosed with late-stage breast cancer after many years of "normal" mammograms.

Leighton died in 2013 at the age of 42 while the documentary was being filmed.

The film features several women who were not informed of their breast density, or of the increased cancer risk that dense breast poses, or of the fact that mammograms can — and frequently do — miss cancer when you have dense breasts.

This includes someone on my staff, Cindy Bevington Olmstead, a Midwest journalist whose 5 cm lesion was missed by a mammogram two years in a row. Olmstead was lying on a gurney outside the operating room, waiting to have her breast removed when she opened a piece of mail brought to her by a neighbor.

In it was a "Happygram" from the breast center that did her latest mammogram, just three weeks earlier. "We are pleased to inform you that we have found no evidence of cancer in your breast," the letter said.

As noted by Marron:

"What stands out in all the stories in this film is that everyone's cancer was missed by a mammogram, and you just don't hear about that when breast cancer awareness month rolls around.

We hope to highlight the importance of knowing your breast density, so that no woman ever has to go through what these women did."

Withholding Information Places Women at Risk for False Negatives

Forty-nine percent of women have high breast tissue density,1 and mammography's sensitivity for dense breasts is as low as 27 percent.2 This means nearly 75 percent of dense-breasted women are at risk for a cancer being missed if they rely solely on mammography.

Even with digital mammography, the sensitivity is still less than 60 percent. The "density" refers to higher levels of fibrous and glandular tissue in the breast relative to fatty tissue.

The reason mammography frequently fails to pick up cancer in dense breast tissue is because the X-ray image shows the breast tissue as areas of white and dark, with white areas indicating denser tissue — including cancerous lesions — and darker areas less dense and more fatty tissues, through which the X-rays pass more readily.

When a woman's breast is very dense, lesions are less likely to be identified among the natural fibrous tissue since both show as white on the x-ray.

The failure rate of mammography among dense-breasted women is known in the medical community, yet dense-breasted women are rarely informed that they may be at an increased risk for a false negative, and thousands of women die as a result of the cancer being missed.

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Dense-Breasted Women Also Have an Increased Risk for Breast Cancer

In addition to being more prone to false negatives, dense-breasted women are also more likely to develop breast cancer than women with less dense breasts, with makes the ineffectiveness of mammograms for these women an even greater concern.

According to the website BreastDensity.info,3 which was created by a radiologist:

  1. If the report states her density is heterogeneously dense, this is associated with minimal risk above average (RR=1.2 compared to average breast density).
  2. If her density is extremely dense (also sometimes called simply dense), this factor doubles her risk of breast cancer compared to average density, similar to the risk associated with a family history of breast cancer in a mother, sister, or daughter.
  3. For example, having extremely dense tissue on its own raises the 10-year risk of breast cancer in the average 50-yr old woman from 1 in 42 to 1 in 21. [Emphasis mine]

A paper4 published in the Journal of the National Cancer institute in 2000 notes that dense-breasted women have a four to six-fold increased risk for breast cancer, adding that "only age and BRCA1 and BRCA2 mutations increase risk more." Interestingly, this was recently refuted by a Croatian study.5

According to the authors, no significant difference in breast density between breast cancer patients and the healthy controls could be found after analyzing data from nearly 53,000 mammograms.

Some have suggested this is little more than an attempt to save the mammography industry by insinuating that dense-breasted women don't have to worry about the fact that mammography misses a majority of their cancers. But it's also interesting to note the timing of this finding.

It came out shortly after a Chinese study revealed ultrasound to be considerably superior to mammography, especially for dense-breasted women. (I'll discuss that study further below.)

Mandatory Breast Density Reporting Laws

To address the risks dense-breasted women face when using mammography for early breast cancer detection, a number of states have passed mandatory breast density reporting laws. This movement was initiated by Nancy Cappello, PhD, whose breast cancer was missed due to her breast density. Just months after receiving a negative mammogram, her gynecologist discovered a lump in her breast. Additional testing revealed she had advanced cancer.

The mission of Cappello's organization, "Are You Dense? Advocacy,"6 is:

"To ensure that women with dense breast tissue have access to an early breast cancer diagnosis. To that end, women need to be informed of their breast density, the limitations of mammography to find cancer in dense breast tissue and the increased risk factor of dense breast tissue."

At present, 24 states have passed mandatory breast density reporting laws. An interactive map of breast density laws by state can be found on Diagnostic Imaging's website.7 However, as noted by Diagnostic Imaging, notification in and of itself doesn't necessarily solve the problem. Women also need to be told what to do with the information, and certain states are better at communicating this than others.

Some States With Breast Density Reporting Laws Still Fail to Educate Women of Their Status and Risk

Some states have adopted notification letters that raise more questions than they answer. According to Diagnostic Imaging:

"Women with dense breasts are encouraged to discuss with their physicians their possible increased risk of breast cancer and the difficulty that mammography may have in detecting tumors. Critics of such a law or of how such a law is implemented believe that women may receive the information in less than ideal circumstances, which can lead to increased anxiety, as well as additional medical procedures ...

The letter's text varies considerably across the states ... An example of ineffective language used in some states ... say, 'If you have dense breasts,' and then what the options are ... So the woman is going to look at that letter and say, 'Why did I receive this letter?' It doesn't tell her if she does or doesn't have dense breasts, nor does it inform her of her particular situation ... [A] more effective letter ... says, 'Your mammogram shows that your breast tissue is dense' ...

Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer through a mammogram' ... [T]hese lines explain why it might be a good idea for this woman to undergo other imaging techniques. And then the letter goes on to say ... 'Also dense breast tissue may increase your risk for breast cancer.'

The letter continues: 'This information about the results of your mammogram is given to you to raise your awareness. Use this information to talk to your physician'..."

3D Tomosynthesis Voted a Top 10 Medical Innovation for 2014

Unfortunately, instead of admitting the flaws and inherent dangers of mammography, the industry unveiled a "new and improved" type of mammogram in 2011, called 3D tomosynthesis, which actually exposes you to even HIGHER doses of radiation than a standard mammogram. What's worse, they also recommend you continue receiving your traditional 2D mammogram when you get tomosynthesis, thereby multiplying your radiation exposure even further.

According to surgeon Dr. Susan Love,8 tomosynthesis exposes you to about twice the amount of radiation compared to a standard mammogram.

According to one 2010 study,9 annual screening using standard digital or screen-film mammography on women aged 40 to 80 years is associated with an induced cancer incidence and fatal breast cancer rate of 20 to 25 cases per 100, 000. Meaning, annual mammograms CAUSE 20 to 25 cases of fatal cancer for every 100,000 women getting the test.

Further increasing — perhaps doubling — the number of fatal breast cancer caused as a direct result of the screening procedure itself can hardly be called progress! And yet, breast tomosynthesis was voted a Top 10 medical innovation for 2014.10 The reason you don't hear much about safer screening methods, except as auxiliary or supplementary forms of screening, is because mammography is such a tremendous profit center.

Radiology Industry Doesn't Want You to Know That Safer Screening Methods Are Also Superior to Mammography

Many articles expounding the benefits of mammography are written by people in the radiology industry, who have the most to lose should mammography fall out of favor. This is why they typically don't acknowledge the fact that other screening methods are actually superior. This includes ultrasound, which was recently found to be superior to mammography for breast cancer screening in high-risk Chinese women.

Chinese women tend to have small and dense breasts and ultrasound is a common method for breast cancer screening in China. However, its efficacy and cost comparing with mammography has not been evaluated in randomized trials, until now. This study11 found that:

  • It costs 6.5 times more money to detect one cancer with mammography than with ultrasound. More specifically, it costs $7,876 to detect one cancer with ultrasound, compared to $45,253 using mammography
  • Ultrasound picks up more cancers than mammograms, plus it covers dense-breasted women

Bottom line: ultrasounds are cheaper, both in equipment and cost to use,12,13 meaning there will be less reimbursement from insurance and Medicaid/Medicare than with mammograms, plus radiologists have higher salaries than ultrasound techs.

Cancer Prevention Begins With Your Lifestyle Choices

Mammograms are portrayed as the best form of "prevention" a woman can get. But early diagnosis is not the same as prevention. And cancer screening that does more harm than good can hardly qualify as the best you can hope for ... I believe the vast majority of all cancers could be prevented by strictly applying basic, common-sense healthy lifestyle strategies, which includes the following.

This is by no means an exhaustive list. There are many other strategies that can be useful as well. One excellent resource is Dr. Christine Horner's book, "Waking the Warrior Goddess: Dr. Christine Horner's Program to Protect Against and Fight Breast Cancer," which contains research-proven all-natural approaches for protecting against and treating breast cancer.

Eat REAL food; avoid processed foods and sugars, especially processed fructose All forms of sugar are detrimental to health in general and promote cancer. Fructose, however, is clearly one of the most harmful and should be avoided as much as possible.

Reduce non-fiber carbs but have large volumes of fresh organic veggies, along with loads of fat from high quality sources such as avocados, raw butter, seeds, nuts, and raw cacao nibs.
Stop eating AT LEAST three hours before going to bed There is quite compelling evidence showing that when you supply fuel to the mitochondria in your cells at a time when they don't need it, they will leak a large number of electrons that will liberate reactive oxygen species (free radicals), which damage mitochondrial and eventually nuclear DNA.

There is also evidence to indicate that cancer cells uniformly have damaged mitochondria, so the last thing you want to do is eat before you go to bed. Personally, I strive for six hours of fasting before bedtime.
Optimize your vitamin D Vitamin D influences virtually every cell in your body, and is one of nature's most potent cancer fighters. Vitamin D is actually able to enter cancer cells and trigger apoptosis (cell death).

If you have cancer, your vitamin D level should be between 50 to 70 ng/ml. Vitamin D works synergistically with every cancer treatment I'm aware of, with no adverse effects.
Limit your protein Newer research has emphasized the importance of the mTOR pathways. When these are active, cancer growth is accelerated.

To quiet this pathway, I believe it may be wise to limit your protein to one gram of protein per kilogram of lean body mass, or roughly a bit less than half a gram of protein per every pound of lean body weight.

That is roughly 40 to 60 grams per day. It would be unusual for most to need more than this.
Avoid unfermented soy products Unfermented soy is high in plant estrogens, or phytoestrogens, also known as isoflavones.

In some studies, soy appears to work in concert with human estrogen to increase breast cell proliferation, which increases the chances for mutations and cancerous cells.
Improve your insulin and leptin receptor sensitivity The best way to do this is by avoiding sugar and grains and restricting carbs to mostly fiber vegetables. Also making sure you are exercising, especially with high intensity interval training.
Exercise regularly One of the primary reasons exercise works to lower your cancer risk is because it drives your insulin levels down, and controlling your insulin levels is one of the most powerful ways to reduce your cancer risks.

It's also been suggested that apoptosis (programmed cell death) is triggered by exercise, causing cancer cells to die.

Studies have also found that the number of tumors decrease along with body fat, which may be an additional factor.

This is because exercise helps lower your estrogen levels, which explains why exercise appears to be particularly potent against breast cancer.

Finally, exercise increases mitochondrial biogenesis, which is essential to fight cancer.
Maintain a healthy body weight This will come naturally when you begin eating right for your nutritional type and exercising. It's important to lose excess body fat because fat produces estrogen.
Drink a pint to a quart of organic green vegetable juice daily Please review my juicing instructions for more detailed information.
Get plenty of high quality animal-based omega-3 fats, such as krill oil Omega-3 deficiency is a common underlying factor for cancer.
Use curcumin This is the active ingredient in turmeric and in high concentrations can be very useful adjunct in the treatment of cancer.

For example, it has demonstrated major therapeutic potential in preventing breast cancer metastasis.14 It's important to know that curcumin is generally not absorbed that well, so I've provided several absorption tips here.
Avoid drinking alcohol At minimum, limit your alcoholic drinks to one per day.
Avoid electromagnetic fields as much as possible Even electric blankets can increase your cancer risk.
Avoid synthetic hormone replacement therapy, especially if you have risk factors for breast cancer Breast cancer is an estrogen-related cancer, and according to a study published in the Journal of the National Cancer Institute, breast cancer rates for women dropped in tandem with decreased use of hormone replacement therapy.

(There are similar risks for younger women who use oral contraceptives. Birth control pills, which are also comprised of synthetic hormones, have been linked to cervical and breast cancers.)

If you are experiencing excessive menopausal symptoms, you may want to consider bioidentical hormone replacement therapy instead, which uses hormones that are molecularly identical to the ones your body produces and do not wreak havoc on your system. This is a much safer alternative.
Avoid BPA, phthalates and other xenoestrogens These are estrogen-like compounds that have been linked to increased breast cancer risk.
Make sure you're not iodine deficient There's compelling evidence linking iodine deficiency with certain forms of cancer. Dr. David Brownstein,15 author of the book "Iodine: Why You Need it, Why You Can't Live Without it," is a proponent of iodine for breast cancer.

It actually has potent anticancer properties and has been shown to cause cell death in breast and thyroid cancer cells.

For more information, I recommend reading Dr. Brownstein's book. I have been researching iodine for some time ever since I interviewed Dr. Brownstein as I do believe that the bulk of what he states is spot on.

However, I am not convinced that his dosage recommendations are ideal. I believe they are five to six times higher than optimal.
Avoid charring your meats Charcoal or flame broiled meat is linked with increased breast cancer risk. Acrylamide — a carcinogen created when starchy foods are baked, roasted, or fried — has been found to increase cancer risk as well.