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Discussions of Dense Breasts, Breast Cancer Risk, and Screening Choices in 2019

Educational Objective
To understand how breast density combined with breast cancer risk can affect screening choices
1 Credit CME

Breast density, a radiologic term that describes the proportion of parenchymal relative to fatty tissue in mammograms, is a strong and prevalent risk factor. With increasing breast density, the risk of having a breast cancer masked or hidden on mammography increases, as does future breast cancer risk.1 Almost 50% of US women aged 40 to 74 years have dense breasts (an estimated 27.6 million women). The widespread incorporation of breast density information into screening mammography reports in 36 US states and suggestion to consider supplemental imaging has resulted in women raising questions about breast density and supplemental imaging with their clinicians.2 Thus, clinicians need to be knowledgeable of the clinical significance of breast density and how it may be useful when combined with breast cancer risk to inform screening discussions.

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Article Information

Corresponding Author: Karla Kerlikowske, MD, San Francisco Veterans Affairs Medical Center, General Internal Medicine Section, 111A1, 4150 Clement St, San Francisco, CA 94121 (Karla.Kerlikowske@ucsf.edu).

Published Online: May 31, 2019. doi:10.1001/jama.2019.6247

Conflict of Interest Disclosures: Dr Kerlikowske reported receiving grant support from the National Cancer Institute and the Patient-Centered Outcomes Research Institute during the conduct of the study, receiving grant support from Google Sciences, and is a nonpaid consultant with GRAIL on the STRIVE study. Dr Miglioretti reported receiving grants from the National Cancer Institute and the Patient-Centered Outcomes Research Institute during the conduct of the study and personal fees from Hologic for serving on the scientific advisory board outside the submitted work. Dr Vachon reported receiving grants from GRAIL and having a patent to an automated breast density measure issued. No other disclosures were reported.

Additional Contributions: The authors thank Kathleen R. Brandt, MD (Mayo Clinic), for her critical review of the article.

References
1.
Kerlikowske  K, Zhu  W, Tosteson  AN,  et al; Breast Cancer Surveillance Consortium.  Identifying women with dense breasts at high risk for interval cancer.  Ann Intern Med. 2015;162(10):673-681.PubMedGoogle ScholarCrossref
2.
Cappello  NM, Richetelli  D, Lee  CI.  The impact of breast density reporting laws on women's awareness of density-associated risks and conversations regarding supplemental screening with providers.  J Am Coll Radiol. 2019;16(2):139-146.PubMedGoogle ScholarCrossref
3.
Tice  JA, Miglioretti  DL, Li  CS, Vachon  CM, Gard  CC, Kerlikowske  K.  Breast density and benign breast disease: risk assessment to identify women at high risk of breast cancer.  J Clin Oncol. 2015;33(28):3137-3143. doi:10.1200/JCO.2015.60.8869PubMedGoogle ScholarCrossref
4.
Tice  JABM, Bissell  MCS, Miglioretti  DL,  et al.  Validation of the breast cancer surveillance consortium model of breast cancer risk  [published online February 22, 2019].  Breast Cancer Res Treat.PubMedGoogle Scholar
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Brentnall  AR, Cuzick  J, Buist  DSM, Bowles  EJA.  Long-term accuracy of breast cancer risk assessment combining classic risk factors and breast density.  JAMA Oncol. 2018;4(9):e180174.PubMedGoogle ScholarCrossref
6.
Lee  A, Mavaddat  N, Wilcox  AN,  et al.  BOADICEA: a comprehensive breast cancer risk prediction model incorporating genetic and nongenetic risk factors  [published online January 15, 2019].  Genet Med. doi:10.1038/s41436-018-0406-9PubMedGoogle Scholar
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Ohuchi  N, Suzuki  A, Sobue  T,  et al; J-START investigator groups.  Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-cancer Randomized Trial (J-START).  Lancet. 2016;387(10016):341-348.PubMedGoogle ScholarCrossref
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Bakker  MF LS, Pijnappel  RM, Mann  RM,  et al. Additional MRI screening in women with extremely dense breasts: primary outcome of the first round of the randomised DENSE trial. Presented at: European Congress of Radiology; March 1, 2019; Vienna, Austria.
9.
Trentham-Dietz  A, Kerlikowske  K, Stout  NK,  et al; Breast Cancer Surveillance Consortium and the Cancer Intervention and Surveillance Modeling Network.  Tailoring breast cancer screening intervals by breast density and risk for women aged 50 years or older.  Ann Intern Med. 2016;165(10):700-712.PubMedGoogle ScholarCrossref
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Kerlikowske  K, Zhu  W, Hubbard  RA,  et al; Breast Cancer Surveillance Consortium.  Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy.  JAMA Intern Med. 2013;173(9):807-816.PubMedGoogle ScholarCrossref
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