Katie Couric wants all women who undergo a mammogram to learn whether they have dense breasts, and how that impacts cancer detection and their cancer risk.
The former TODAY host was diagnosed with breast cancer this summer after getting a mammogram and another test, she revealed in an essay on her website on Sept. 28, 2022.
"Because my breasts are dense, I routinely get an additional screening using a breast ultrasound," she wrote.
"The denser your breasts, the higher your risk of cancer. In 2019, the FDA proposed federal legislation that would make the language and guidance more specific, but the agency has been dragging its feet. Let's get a move on, folks."
The information would be part of the letter every woman gets after her breast cancer screening, the U.S. Food and Drug Administration proposed in March 2019. It would explain how breast density can influence the accuracy of mammograms and recommend patients with dense breasts talk to their doctor about what it means and how it relates to their breast cancer risk.
Having a national standard would help ensure every woman gets the most accurate information she needs after a mammogram, said Lisa Lacasse, president of the American Cancer Society Cancer Action Network, in a statement at the time.
But more than three years later, the final rule still hasn't been published.
"The FDA is committed to improving mammography services for patients and working diligently to finalize the rule to amend the existing mammography regulations," Shauna Nelson, a spokesperson for the agency, told TODAY in a statement on Sept. 28, 2022.
Women in many parts of the country already receive this notification: 38 states have breast density reporting laws, according to DenseBreast-info.org, a non-profit organization dedicated to the topic. That's thanks to grassroots efforts by patients who felt blindsided because they weren’t told their mammograms could be more difficult to interpret.
What does it mean if a patient has dense breasts?
TODAY asked Dr. Deanna Attai, past president of the American Society of Breast Surgeons and an associate clinical professor of surgery at the David Geffen School of Medicine at the University of California Los Angeles; and Dr. Dana Smetherman, past chair of the American College of Radiology Breast Imaging Commission and chair of radiology at Ochsner Medical Center in New Orleans.
What does it mean if a woman has dense breasts?
It has to do with the proportion of fatty tissue, glandular tissue and fibrous connective tissue in the breast. The more fibro-glandular tissue a woman has, the denser the breast.
Age is the biggest factor: Younger women naturally tend to have denser breast tissue. As estrogen levels drop with menopause, much of that glandular tissue gets replaced by fatty tissue.
Thinner women often have dense breast tissue. For others, it’s hereditary or just how they’re born. More than half of women over 40 in the U.S. have dense breasts, which is a risk factor for developing breast cancer, the FDA noted.
Having dense breasts is not something a person can see or feel — it’s different from having a lumpy breast, Attai said — rather, it’s determined by a mammogram.
How do dense breasts affect mammogram readings?
Dense tissue shows up as white on X-rays — think of how bones stand out in those images.
“When I as a breast imaging radiologist describe a patient as having dense breasts, what I mean is that her mammogram looks white to me,” Smetherman said. “Cancers will also look white, so looking for something white on a background of white is more difficult to identify.”
Fatty tissue, on the other hand, looks gray on a mammogram, so a tumor stands out.
Should women with dense breasts still have a mammogram?
Absolutely, both experts emphasized. “That’s a very, very important message,” Smetherman noted. Women will still benefit from mammography, which is the only FDA-approved screening tool for breast cancer.
Mammograms are sometimes the only way to detect calcifications, which are associated with early stages of breast cancer in some cases, Attai said.
What are the next steps for women with dense breasts?
A 3D mammogram can improve the cancer detection rate, Attai said. It’s not always covered by insurance.
A breast ultrasound or a breast MRI can be helpful as supplemental screenings, but those tests are not automatically recommended. They may find more suspicious spots — which may lead to biopsies and other invasive procedures — but there hasn’t been much data to show they improve survival.
“The harder we look, the more we’re going to find. Not everything we find needs to be found. With all of these tests, there are false alarms, false positives,” Attai said. “There’s a lot of nuance to this — it’s not quite black and white.”
“It’s one reason why we have to be very cautious before you say, ‘Yes, everybody with dense breasts should have this additional thing’,” Smetherman added.
Right now, women who have dense breasts and who are considered to have a high lifetime risk of developing breast cancer — perhaps because of family history or other factors — get a routine annual MRI, Attai said.
Does the FDA proposal mean insurance would cover the cost of additional screening for women with dense breasts?
No, at least not yet. The proposed change would “enhance the communication of important clinical information” between patients, doctors and mammogram centers, but the FDA doesn’t regulate insurance coverage, said Megan McSeveney, a spokeswoman for the agency.
Some states require insurance to cover supplemental screening beyond mammography, according to DenseBreast-info.org. The majority don't.
The typical out-of-pocket cost for a breast screening ultrasound is about $250, according to the Brem Foundation to Defeat Breast Cancer. The average cost of an MRI is about $1,084, it noted.
When Attai recommends supplemental screening for women who have a high risk of developing breast cancer, she usually has no problems getting their insurance to cover those tests. For all other women, it’s all across the board. The FDA’s proposal could be a first step in changing that, she said.
“It’s going to take a lot to change insurance companies,” Attai noted. “(But) coming from a federal level, that may… help influence insurance companies to cover supplemental screening or at least 3D mammography.”
This article was originally published on TODAY.com