Breast density and its relation to breast cancer was brought to light for us last year when we interviewed Parkland’s Tammy Krichmar. Tammy, who was also our boxing glove cover model, is just one of many women who consistently received false negatives from mammograms. What she and many others weren’t made aware of is that there’s a measurement being taken during the mammogram that doctors aren’t required to tell their patients—that measurement is breast density. “I was diagnosed later than most women due to the lack of information I was given by my then radiologist and breast surgeon,” said Tammy. “This time last year, I underwent a double mastectomy, which was a very hard decision to make. I would come to realize that decision had saved my life. After pathology came back it showed in one of my breasts they had found cancer ‘in-situ’—pre cancerous cells—in every quadrant of my breast. For sure these little ‘pre cancer cells’ would grow up to be very aggressive big cancer cells. I have come to know many women who had decided to go the route of lumpectomy and radiation and are now fighting cancer that has metastasized to their brain.

“There are many factors involved in making the decision on what type of surgery to have and it is based on you, your family and your doctors, the DNA of your tumor, how aggressive your tumor is, and what the recurrence rate is. But at the end of the day, there wasn’t much of a decision for me to make. I was 45 and a new grandmother—I was going to do everything in my power to grow old with my husband and see our children and grandchildren grow.”

What is “Breast Density”? - As we learned last year, breast density has little to do with breast size. On mammogram film, fat appears as a dark area, and tumors appear as a solid white area. However in a woman with dense breasts, the dense breast tissue also appears as a solid white area, making it more difficult to detect a tumor since it blends in with the dense tissue that surrounds it. But studies show that having extremely dense breasts can make you four to six times more likely to get breast cancer.

While lifestyle factors can influence breast density, studies also show that the underlying causes are mostly inherited. Higher breast density is more common in younger women from puberty through the childbearing years, and generally decreases during menopause when the milk-glands and ducts atrophy and connective tissue disappears. But that isn’t the case for all women; for some, these tissues persist and those women are the ones who are at higher risk.

How Do I Know If I Have Dense Breasts? - Unless you live in California, Connecticut or Texas, your radiologists and/or physicians are not required by law to notify you that you have dense breasts. Is that not ridiculous?? This means, if you have dense breasts in the other 47 states, you have a higher chance of getting a false reading from your mammogram and never know it. So how do you know if you have dense breasts if you aren’t told? You NEED to ask, “What is my current breast density measurement?” You should get a rating between 1 and 4 (1 for predominately fat to 4 for extremely dense) that lets you know how dense your breasts are.

What do I do if I Have Dense Breasts? - There are many options you can discuss with your doctor about getting a more accurate test result. The traditional approach has been to get an MRI test. But the problem with the MRI tests is that they are very expensive and often pick up everything. MRI tests can be over sensitive and “over-precise” at times—picking up many things that, once biopsied, could turn out to be nothing. Two other screening options may be more accurate and affordable. The first option is DXAs, which are traditionally used to measure bone density and total body composition. Lucky for us, DXAs are also able to give us breast density measurements that couple well with current mammogram results. The second screening option is the new stereo mammograms. In recent studies, the stereo mammograms reduced false-positive findings by 49% compared to standard digital mammography, and reduced missed lesions by 40%. Both the DXAs and stereo mammograms may be less expensive and a better fit for detecting breast cancer than MRIs, so consult your physician as to whether they are good screening options for you.

Can I Reduce Breast Density? - The drug Tamoxifen may be an option for women with dense breasts. The drug is already FDA approved for breast cancer treatments (and to help reoccurrences of cancer with remission patients). Currently, Tamoxifen is also going through trials to see if it can reduce breast density as well. In a 2008 trial (reported at the San Antonio Breast Cancer Symposium), women were given Tamoxifen so researchers could observe the drug’s effects on breast density. It was reported that trial participants saw at least a 10% reduction in breast density over the first 12 to 18 months.

In addition to Tamoxifen’s trials on breast density reduction, trials are also in place to see Tamoxifen’s potential at preventing estrogen-based breast cancers. Tamoxifen’s side effects are similar to other estrogen-moderating drugs, such as the birth control pill. Women should be aware that this is a drug that changes the amount of estrogen naturally produced in their bodies. Note, not all types of breast cancers are affected by Tamoxifen, because not all breast cancers stem from mutations in estrogen (see Triple-Negative Breast Cancer article on page 70).

Dr. Norman Boyd, a catalyst in the breast cancer research field (the senior scientist at the Campbell Family Institute for Breast Cancer Research at the Ontario Cancer Institute in Toronto), hopes that in the future, density measurements will not only be a key to factoring breast cancer risk, but a means for treatment. “Theoretically,” he said, “in the same way that people now take drugs to lower their cholesterol and thus their risk of heart attack or stroke, you could someday take a drug to lower your breast density—and thus your risk of breast cancer.”

Diagnostic Information

Mammograms - Mammography saves lives. It significantly improves detection of breast cancer at an early stage, when it’s most treatable. A mammogram is an x-ray taken by flattening women’s breasts between two plates. Having a yearly mammogram lets your radiologist compare breast changes from year to year to better appreciate the presence of abnormalities. Routine mammography saves lives.

Clinical Breast Exam - All patients are offered the opportunity to have a clinical breast exam prior to a mammogram. This step is often valuable in identifying issues that could be missed in a mammogram and sometimes things can be detected through touch that are harder to detect in a mammogram or ultrasound. The results of the risk assessment, together with the breast exam, enable your health care provider to determine the best screening plan for you.

Breast MRI and Breast Ultrasound - MRI & ultrasound provide additional ways for radiologists to see breast tissue and detect abnormalities. Magnetic Resonance Imaging (MRI) uses a powerful magnet linked to a computer to produce detailed pictures and is appropriate for women who: Test positive for the BRCA1 or BRCA2 gene mutation (see additional story this issue); Have a parent or sibling who carries a breast cancer gene; Have a greater than 20% lifetime risk of developing breast cancer, as determined by their physician or genetic counselor; Received radiation treatment to the chest between age 10-30; Have a close relative with certain genetic syndromes such as Li-fraumeni or Cowden.

Genetic Links to Breast Cancer - Genetic counseling is covered by most insurance and includes a full review of your medical and family history. If your history indicates likelihood, the counselor will order a blood test. The test can detect two of the most well-known breast cancer genes-BRCA1 and BRCA2. Women who test positive for the gene can take steps to reduce their risk, including; starting breast cancer screenings earlier in life; have more thorough breast cancer screenings; taking medications that reduce risk; considering preventative surgical procedures. 

Biomarkers for Cancer - The following is a list of several biomarkers for well-known common cancers. Newer diagnostic testing companies have been able to develop a panel of markers that can detect whether an individual has high levels of inflammation and if this is associated with a particular cancer in the body. By analyzing your personal biomarker panel together with checking the level of inflammation, you can see if you are at high risk to develop certain cancers.

AFP (alpha fetal protein): This is increased in 80 percent of people with liver cancer and 60 percent of patients with testicular cancer. Adding an HCG test picks up even more patients at risk.

Ca 125 (Cancer antigen 125): It’s noted to be elevated in 50 percent of patients with early ovarian cancer and up to 80 percent with late ovarian cancer. It’s also seen in early stage breast cancer.

Ca 15-3 (Cancer antigen 15-3): It’s seen in approximately 21 percent of early and up to 95 percent of late-stage breast cancer.

Ca 19-9 (Cancer antigen 19-9): It’s increased in 80 to 90 percent of pancreatic cancer patients and about 60 to 70 percent of biliary cancer patients.

CEA (Carcinoembryonic antigen): It’s elevated in about 75 percent of patients with colon cancer, 64 percent with late-stage breast and 10 percent with early stage breast cancers.

NSE (non-specific enolase): It’s noted to be increased in 60 to 100 percent of small-cell lung cancer.

Our courageous pint-size cover girl Tammy Krichmar formed the non profit organization, “I’m Dense Are You?” (www.imdense.org) to fight for other women who have dense breast tissue in the state of Florida. “I had begged and pleaded for someone in our Legislative system to listen to my case and help write a Senate Bill that would add density information to the mammogram ‘lay letter,’ the letter you receive after your mammogram, that tells you it was normal,” said Tammy. “Parkland’s own Senator Jeremy Ring said he would champion this bill, the Breast Density Senate Bill SB96. The information added to the lay letter would say if in fact you have dense breasts you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors.”

Krichmar, along with six other women, also co-founded the Density Education National Survivors Effort,” or D.E.N.S.E., to take it on at a national level. “At this time, Connecticut and Texas have passed their Bills, California has found its way onto the Governor’s desk for signature, Missouri has been working for a year and now Maine and New Hampshire both have started the legislative process. And then there is Florida … unfortunately at this time the Florida Medical Association road blocked our Bill because they do not want to be mandated. They have, however, agreed to back educating the physicians and patients. I’d love to walk into an imaging center and see a poster on the wall asking if you know what your breast density is. I will be speaking at the Broward County hearings on this matter on October 27, hoping to continue to raise awareness.” (Stay tuned to lifepubs when Tammy reports the results).

Komen has partnered with D.E.N.S.E. to look for a solution to this matter, stating that more specific and sensitive early detection tools are needed. According to Tammy, Komen has invested more than $40 million in early detection research on projects that are focusing on innovation, such as developing new imaging technologies that provide enhanced, three-dimensional images and are more comfortable; exploring whether genetic codes (biomarkers) in tissue or fluid can be used to create screening tests; identifying ways to detect aggressive subtypes, such as inflammatory breast cancer and triple negative breast cancer; and understanding how breast density impacts the effectiveness of different screening technologies. “Komen believes increasing the variety of screening technologies available to women is critical to a woman’s right to access the screening tools that may save her life,” she said.

While Tammy had hoped to have made more progress in the state of Florida over the past year, she acknowledges it’s better than the current protocol, which is to do nothing. “I wonder how many women will be going through what I’ve been going through the last couple of years if in fact it is not mandated that EVERY WOMAN be informed thoroughly on this issue. I will continue in the education and focus on better screening techniques for breast cancer to hopefully help find it earlier and earlier when the treatment is less toxic so a woman doesn’t have to lose her breasts.”

It’s been a challenging year both mentally and physically for Tammy, between her work on I’m Dense Are You? and D.E.N.S.E, and her recent diagnosis of a malignant melanoma on her lower calf. “It was just another mole that I had for quite a while but it was half a centimeter in size and just didn’t look right. My plastic surgeon, who was involved from my mastectomy through reconstruction, removed a chunk about the size of a silver dollar in diameter and ½ centimeter in depth. After two weeks of healing, I went back for skin graft surgery. I was totally unaware that breast cancer and skin cancer are often found in the same patients. Why? More research is needed (I love that line). Somebody said to me it’s just skin cancer, they just cut it off—NO!! If it isn’t caught in the early stage the cancer cells get into your body and there really isn’t a cure—if you don’t catch it in time you die—FROM A MOLE! There is so much more to know about all cancers and I encourage women to go for their yearly mammograms and yearly dermatology check ups. After all I went through I couldn’t imagine being taken out by a mole!”

For Tammy, the battle never ends. As soon as she recovers from her most recent surgery, she’ll once again throw herself into the battle of educating the state on this issue. “If cancer is caught in the earliest stages it saves dollars for the state, insurance premiums and of course it saves LIVES. Already a couple of my amazing co-founders of D.E.N.S.E. have developed brain metastasis which means the breast cancer cells have traveled to their brains. They will undergo additional treatment, heartache, sickness and usually radiation. I continue to pray for these women who are a part of this breast cancer club. A group that I unknowingly became a member of and one that only those who have gone through it could understand how emotionally vested we are. Be careful and stay on your toes, you never know when and if you will be drafted into our special club.”