Rationale and Objectives
This study aimed to assess radiologists’ knowledge about breast density legislation as well as perceived practice changes resulting from the enactment of breast density legislation.
Materials and Methods
This is an institutional review board-exempt anonymous email survey of 523 members of the New England Roentgen Ray Society. In addition to radiologist demographics, survey questions addressed radiologist knowledge of breast density legislation, knowledge of breast density as a risk factor for breast cancer, recommendations for supplemental screening, and perceived practice changes resulting from density notification legislation.
Results
Of the 523 members, 96 responded, yielding an 18% response rate. Seventy-three percent of respondents practiced in a state with breast density legislation. Sixty-nine percent felt that breast density notification increased patient anxiety about breast cancer, but also increased patient (74%) and provider (66%) understanding of the effect of breast density on mammographic sensitivity. Radiologist knowledge of the relative risk of breast cancer when comparing breasts of different density was variable.
Conclusions
Considerable confusion and controversy regarding breast density persists, even among practicing radiologists.
Introduction
Within the United States, breast density notification legislation was first passed in Connecticut in 2009, but the topic remains confusing and controversial for patients, providers, and radiologists alike. Among the other New England states, density notification legislation was enacted in Rhode Island in 2014, Massachusetts in 2015, and Vermont in 2016; Maine suggests notification but does not require it, and New Hampshire does not currently have a legislative density bill . Given the state-to-state differences across the United States, it is not surprising that a recent study from the Mayo Clinic showed considerable variability in provider knowledge about breast density laws and recommendations for supplemental screening at the multiple Mayo Clinic sites.
Reasons for persistent confusion abound. First, determination of breast density can be both subjective and variable , even with automated software programs . In addition, recent changes to breast density assessment in the fifth edition of the American College of Radiology Breast Imaging-Reporting and Data System Atlas emphasize the clinical importance of the masking effect of breast density on mammographic sensitivity. Radiologists’ subjective density assessments have also been shown to change following enactment of breast density legislation, with more women being categorized as non-dense rather than dense . For women with dense tissue who are at elevated (>20%) lifetime risk for breast cancer, adjunctive screening magnetic resonance imaging (MRI) is recommended . However, for women with dense breasts who are at average or intermediate lifetime risk for breast cancer, there is no consensus or professional society guideline for what, if any, additional imaging should be undertaken. In Massachusetts, a multidisciplinary expert panel proposed a practice guideline, but clinical practice remains inconsistent. Insurance coverage for additional screening examinations is also quite variable, and the breast imaging community remains under scrutiny for false positives resulting in additional imaging or benign biopsy. In addition, there is persistent debate about how frequently and at what ages to screen women with mammography, despite the fact that mammography has been shown to decrease breast cancer morbidity and mortality by at least 15% in multiple prospective studies . By comparison, data for adjunctive screening of women with dense breast tissue and negative mammograms remain relatively sparse .
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Materials and Methods
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Results
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TABLE 1
Demographics of Survey Participants
Respondent Demographics Age 50 and over 72% (69/96) Male 55% (53/96) Private practice 54% (51/94) No breast imaging fellowship 82% (79/96) 50% or less breast imaging 70% (67/95) Practice in state with density legislation 73% (69/94)
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TABLE 2
Perceived Effects of Breast Density Legislation
Breast Density Legislation Increased patient anxiety about breast cancer 69% (57/83) Increased patient awareness about density’s effect on mammographic sensitivity 74% (61/82) Increased provider awareness about density’s effect on mammographic sensitivity 66% (54/82)
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Discussion
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