New national guidance helps GPs manage patients who have dense breasts – but breast density information is only given to women in some states.
A new step-by-step guide helps GPs manage patients who report high breast density and have other risk factors for breast cancer – but only women in some states will know whether they have dense breasts or not.
The new guide – with bonus flow chart – spells out screening options for patients depending on their breast density and whether they have high, moderate or average overall breast cancer risk.
According to BreastScreen Australia, women with dense breasts have a slightly increased risk of breast cancer. Mammography sensitivity is 90% for women with low density breasts, 84% for women with dense breasts and 64% for women with extremely dense breasts.
Breast density – the amount of fibroglandular tissue in the breast – appears white on a mammogram just like cancer does, potentially leading to a false negative screening result.
Breast Cancer Network Australia’s Director, Policy, Advocacy & Support Services, Vicki Durston, said the new guidance would help GPs manage patients who come into the clinic and say, “I have extremely high breast density, what do I do now?”
But only NSW, Victoria, South Australia and Western Australia report breast density information to women when having mammograms, she said.
“Where we haven’t seen the uptake and prioritisation of breast density reporting has been in Queensland, the Northern Territory, Tasmania and the ACT,” Ms Durston told TMR.
“In some states, you will get more information through your screening appointment than you will in other states, and that’s not what we want to see.
“Every state prioritises their screening program differently, despite it being a Commonwealth-funded program.
“We’re really pleased to see these guidelines, but it reinforces the need for these other states that have been slow off the mark to prioritise breast density reporting in their screening programs.”
Ms Durston said a national statement released earlier this year called for all states and territories to implement breast density reporting for all breast screens.
“Since that statement came out, we have been engaging with those states and territories, and right now, there is not a prioritisation to implement breast density reporting,” she said.
“There’s really limited rationale for that, because it isn’t that costly, and it doesn’t require significant change that cannot be learned from those states that have already implemented it in short timeframes.
“There’s a national evidence-based statement, and states are not following it.”
Ms Durston said a delay in implementing breast density reporting in some states and territories would lead to missed breast cancer diagnoses.
“We want to see this not fall off the radar of state governments with this notion of, ‘we’ve got a strategy, but it’s two years away’,” she said.
“They’ve known about this. They’ve been part of the consultation process. They knew this was coming over two years ago.
“So in some states, you’ll see a four-year delay, which means cancers are being missed and not picked up.”
In the guidance, the authors say breast cancer risk should be considered in the context of other factors such as age, family history, genetics, previous invasive breast cancer, DCIS or other high-risk lesions, use of menopausal hormone therapy, BMI, parity and breastfeeding, and smoking and alcohol consumption.
“There is currently uncertainty regarding the optimal supplemental screening methods for women with high breast density, with clinical evidence developing,” the authors say.
“When discussing any decision about supplemental screening with women who have high breast density, GPs should be clear that a recommendation for further screening does not mean that the woman has breast cancer or has been recalled because of abnormalities suggesting cancer.
“A woman’s decision to have supplemental screening should be fully informed and made in the context of the patient’ s breast cancer risk factors, personal circumstances and preferences.”
The guidance says that if a patient has dense breasts and a high risk of breast cancer – as defined by the RACGP Red Book – they should be referred to a breast surgeon or familial cancer clinic.
For women with BI-RADS d breast density and an average familial risk, GPs should discuss supplemental imaging such as CEM or MRI.
For women with BI-RADS c or d breast density and a moderate risk due to family history, calculate breast cancer risk with a validated breast cancer risk assessment tool such as iPrevent or Tyrer-Cuzick.
That will determine whether they are eligible for an MBS-funded MRI – however, to receive the rebate, patients much be under 60 and the referral must be made by a specialist.
“For those women who do not qualify for an MBS-funded MRI but have BI-RADS c or d density, consider self-funded contrast-enhanced mammography (CEM) or MRI,” the guidance says.
“Digital breast tomosynthesis (DBT) or ultrasound (US) may be considered where CEM and MRI are unavailable.” However, those methods are less sensitive and have higher false positive rates, the authors say.
