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Next Steps After “Dense Breast” Notification

On July 1, 2012, Virginia became the third state in the country to enact a breast density notification law.
The American College of Radiology identifies four categories of breast tissue: (1) almost entirely fatty (less than 25% glandular), (2) scattered fibroglandular densities (25–50% glandular), (3) heterogeneously dense (51–75% glandular), and (4) extremely dense (more than 75% glandular).
Dense breast tissue reduces the sensitivity of mammography. Under the new law, the physician’s office or facility that performed the mammography must notify women with density above 50% (category 3 and 4). Many patients are learning this for the first time and are unsure about the implications, noted Molly Sebastian, MD, FACS, one of two dedicated breast surgeons who are part of the team at the Reinsch Pierce Family Center for Breast Health.

Keep in Mind

  • As of July 2012, Virginia law requires that women with dense breasts receive notification from the facility or physician’s office where the mammogram was performed.
  • Dense breasts do not necessarily place a woman in a high-risk category.
  • The American College of Radiology identifies four types of breast density, from almost entirely fatty to extremely dense.
  • The Center for Breast Health follows NCCN guidelines to help determine further screening.

Breast Center Approach to Dense Breasts

In addition to a physical exam and review of the images, Dr. Sebastian and the team take a detailed personal and family history. They use a breast cancer risk assessment model to help determine whether the patient is at high risk.
Personal factors include exposure to estrogen, fertility, child-bearing history, any previous abnormal biopsies, previous ovarian cancer, DCIS or LCIS, if postmenopausal, and use of hormone replacement therapy. Family history extends to 1st and 2nd degree family members.

  • If a patient with dense breasts is considered high risk—20% risk or above—the Center follows National Comprehensive Cancer Network (NCCN) guidelines, which recommend yearly MRIs in addition to annual mammograms.
  • If a patient with dense breasts is under the 20% threshold, the Center performs 3-D tomosynthesis along with a 2-D mammogram.

Virginia Hospital Center is currently one of two hospitals in Northern Virginia with 3-D technology. Dr. Sebastian said their experience shows 3-D reduces the need for callbacks and increases diagnoses of small cancers. A 2-D mammogram may miss an abnormality in about 10% of women with dense breasts.

Team Approach to Coordinating Care with You

The Breast Center was the first program in Virginia and the DC area to be certified by the American College of Surgeons’ National Accreditation Program for Breast Centers (NAPBC). Their team includes dedicated breast surgeons, radiation and medical oncologists, plastic and reconstructive surgeons, a genetic counselor, supportive counselors, a physical therapist, and others who coordinate diagnosis and treatment with referring physicians.
Notification about dense breasts has increased the anxiety of many patients, whether at high risk or not. Using the Center’s approach so they understand what “dense breasts” means for them helps relieve that anxiety.

What Does the Law Say?

The “dense breast law” is part of an amendment of § 32.1-229 of the Code of Virginia that covers many aspects of radiation services. The law now requires the licensed facility or physician’s office where mammography services are performed to notify patients with dense breasts, using very specific language.
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Molly Sebastian, MD, FACS, is a dedicated breast surgeon and a founding physician of the Reinsch Pierce Family Center for Breast Health. She is a graduate of the University of Virginia School of Medicine, where she received an NSF research grant. She completed her surgical residency at the Medical College of Virginia and received a prestigious NIH Research Fellowship. Board-certified, she completed a fellowship in minimally invasive surgical techniques at Johns Hopkins Hospital.

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