Welcome to Q and A with Dr. K, a podcast by Mountain Pacific Quality Health, where we sit down with Dr. Doug Kuntzweiler and get your health questions answered, because on Q and A with Dr. K, the doctor is always in. Hello everyone. This is Beth Brown, your host. And thank you for tuning in to Q and A with Dr. K. And great news today, we once again, have two times the expertise to talk about our question for today's episode. Joining us are Dr. Doug Kuntzweiler and Dr Tiffany
Kniepkamp. So good to have you both back.
Thank you.
Thanks. Good to be here.
So today's question applies to about two in every
The first thing I would like to say is that this is not a disease. It's not an abnormality. It's like the difference between blue eyes and brown eyes. Really, the five women, so it's pretty common, and what I'm talking vision is the same. Breast functions the same. It doesn't look any different, it doesn't feel any different, but it does about today is dense breasts. So what does a doctor mean when have some important health
implications for women. What it means is that on a mammogram, there is more dense tissue, more they tell a patient they have dense breasts? And how concerned connective tissue, that shows up than in a breast that is deemed to be not dense. So this is sort of a subjective finding. You can should a patient be to get that news? So let's start with what only see it on a mammogram. You can't tell it any other way.
What it consists of is an increase in some of the does a doctor mean when they say to a patient, you have dense connective tissue in the breast, an increase in some of the lobules, which are the milk producing glands and the ducts. breasts? And the ducts are the tunnels that carry the milk from the glands to the nipple so the infant can get the nutrition. And it's just an increase in
that. If you showed the same mammogram to 10 different radiologists, you might get two or three different opinions on how dense that breast was. There's something called BI-RADS, which women may see when they get their mammogram report, and that stands for Breast Imaging and Reporting Data System, and it is a system that radiologists have agreed upon to try and classify these
varying degrees of density. And other than the connective tissue, I talked about, the ducts and the lobules, most of the breast tissue otherwise is fat, which gives the breast, it's it's contour. So when the BI-RAD system the categories, they've divided them into four categories. And the first is category A, which is a breast which has mostly fat and very little of the connective tissue.
Category B has scattered areas of increased density, and that usually doesn't interfere with the ability to read the mammogram. Category C has heterogeneous density, and that means that there's density pretty much throughout the whole breast. And then Category D is
extremely dense. And as I said, this is not a disease, it's just simply a variation, but the denser the breast, the more difficult it is on mammogram to detect a suspicious area, to detect a cancer, and it also does slightly raise a woman's risk of breast cancer.
1.2 times more likely, I believe, is what it was.
I think that's right, I've seen various numbers, but I think the take home is that it does increase your risk, although it's a pretty slight increase, but it does make it more difficult to detect a possible cancer.
Yeah, and Doug, going back a little bit, when talking about the four different categories of density, you may see on your mammogram, they'll talk about fibroglandular tissue, and you definitely touched on this. But just to even break it down further, it's really just like you said, a fancy way to describe parts of the breast that aren't fat, so the fibrous tissue is what helps support and kind of hold the breast
together. Think of it as like connective glue that gives the breast its shape, and then you have the glandular tissue that you were talking about that produces milk. And so those together make up dense breast tissue. And some women have more tissue than fat, which is why they're considered dense. It's totally normal, just something to be aware of. And I do think we're seeing this a ton, because 40 to 50% of women have dense breasts, and we start screening at around 40, depending on risk
factors. And so if you start screening at 40, you do have more dense breast tissue when you're younger. So at least in my age group, I am getting so many questions from my friends, and they're panicking because they get these results saying, I have dense breasts. They want more screening. They want to do more. Am I going to get cancer? And everybody's very worried. But I think the biggest thing is, it's, like you said, not a disease. It's just something to be aware of. So don't be
alarmed. Just be aware.
I was going to hit back on that, too, because we definitely aren't trying to scare half of the women out there who maybe have heard or will hear this from a doctor, or if they get a mammogram. It's not a disease. But then the other thing you talked about too, Dr. K, is you kind of compared it to the eye color. So does that mean breast density is genetic? Or what are the factors that play into whether or not you're a woman who has dense breasts or not,
It is largely genetic, and also, as Tiffany talked about, age, the younger the breast, the more dense it's going to be. And that gradually changes over time, and changes pretty dramatically after menopause. But it seems to be mostly genetic. It's not anything that you've eaten or any anything that you've done that that caused it. I think it's largely genetic.
So then, to that point, then, can women change the density of their breast? Do they have something that they should be thinking about health wise when it comes to that? Or it really just is what it is.
Well, it's interesting. The density does change with a woman's menstrual cycle, and if you are taking exogenous hormones, that means, if you're taking hormones as a pill by mouth or a patch that can have an effect on it.
They actually have looked at lifestyle changes. Diet and exercise really don't significantly impact breast density. But that's interesting, because more lean people do tend to have more dense breasts, because they have decreased in fatty tissue. When they look at it, so say, you do do diet and exercise and you become more lean, it actually doesn't change it much. And so really, you're looking at those hormonal changes. So with aging, it's just going to change, but you
can affect that. So stopping that hormone replacement therapy can reduce your density. Aging, like I said, naturally, decreases it. And diet and exercise, like while it's wonderful and it decreases your overall risk of cancers, doesn't necessarily change the density of your breasts.
One interesting side light to this is there is a difference, and this gets back to the genetic component, there's a difference when you when you look at various ethnic backgrounds. For instance, black women tend to have less dense breasts, but they do have a slightly increased cancer incidence compared to Caucasians and Asians. Asian women tend to have denser breasts, but actually a lower risk for cancer compared
to Caucasians and Blacks. So genetics is definitely playing a role in it, but it kind of really muddies the waters.
Let's go back to something that you said, Tiffany, about women who are getting mammograms and they're hearing this that they have dense breasts, is that how a woman finds out she has dense breasts?
Yes, really, the only way to find out is through mammogram and density testing. You can't necessarily feel a difference. They don't look different. It is just the rating they give it on a mammogram.
Okay, and we've talked about that it can lead potentially or make you at higher risk for breast cancer. Is breast cancer our main concern here? Or are there other issues related to their health that women should be paying attention to if they do know they have dense breasts?
No, I think relative to dense breasts, pretty much detection by mammography is the only real issue. The breast doesn't function any differently. And as we said, your risk is raised, but only slightly. It's interesting to me, the first mammograms were done way back in the early 1900s after, you know, xray was discovered, but it really wasn't used for much of
anything until the 1960s. I went to medical school and got into medicine in the late 70s, and at that time, as I recall, there was not a lot of screening going on. Mammography was used more if a woman had a mass that you could feel or a lump that felt suspicious, then you got a mammogram to see if it had any characteristics that might lead you believe that was possibly a cancer. But there wasn't a lot of mass screening, and that really didn't happen, as I recall, until maybe the late
80s. It just wasn't commonly
done. But mammography, like everything else in medicine, has gotten much more sophisticated, and initially it was done on film, just like old x rays were put on film, and now almost all mammography is digital, which has improved the quality and the ability to analyze the mammogram, and I don't know exactly what the prevalence is, but 3D mammography, which is again, a more sophisticated way to look at it, looking at it from many different angles and constructing a 3D image of the
breast, has helped quite a bit. So if you're told that you have dense breasts, I think it would be important to know exactly what technique they were using. Was it a 3D study, and was it digital?
So should women with dense breasts get more frequent mammograms, or are there other screenings they should be looking into, especially if, say they know because of other risk factors, they might have a higher potential for breast cancer?
Yeah, Beth, so you don't necessarily have to get mammograms more frequently, but as Doug mentioned, you may benefit from additional screening, and your doctor can talk you through this, depending on your risk factors. A good way to think about dense breasts is it gives you an ever so slightly higher risk of breast cancer. Think of it as the same amount of risk as if a family member had cancer in the past. That's about your risk level. And so they'll take that with other aspects of your risk
factors. Do you smoke? Do you drink alcohol? Primary or first cousin or parent, more immediate family that had cancer, and then they'll determine if you need further testing, because on those mammograms. Dense tissue shows up as white, and breast cancer shows up as white as well. So you can imagine, if you've got very or extremely dense breasts, it would be difficult to spot a cancer
because it's all white. And so they may recommend, like Doug said, a breast MRI, 3D mammography, there's breast ultrasound, and then they can actually do contrast enhanced mammograms as well. Not all facilities offer that, and some of these are not covered by insurance yet, but they can help to detect based on the risk factors and what your doctor recommends.
If a woman is diagnosed with breast cancer, will her treatment be different if she has deadness breasts?
No, I would say it really doesn't affect the treatment at all. It's the same. It's just the detection that is more difficult.
And we know that men can get breast cancer too. It's obviously not as common in men as it is in women. Can men also have dense breasts?
Breast cancer in men is exceedingly rare, but it does happen, and the normal male breast is pretty much just all fat, but if you are developing a cancer, you do show breast density on the mammogram. It's difficult to do on males, because there just isn't much tissue that you can you can see to image, but it's usually palpable in a male, so that's largely the way it's discovered. But the male breast, if it gets a cancer, does have more density.
And I would say also, we don't typically screen men. You know, we screen men for prostate cancer, but we don't necessarily screen for breast cancer because it is rare, and, like Doug said, more palpable usually. So you will have signs, and it'll be based on those signs that you will determine if further imaging is needed.
I guess the bottom line then would be, what is the key takeaway message? Going back to that original question of, how concerned should a woman be to hear that she has dense breasts?
I would say the bottom line, dense breasts are not a disease. Half of women who get their first mammogram are going to hear that they have dense breasts, which means half of your friends are going to say, what does this mean? I would think of it as a heads up, not a warning sign. And the good news is now that you know, you and your doctor can stay on top of your breast health. Make sure you get breast screenings, make sure you are doing the correct screenings
based on your risk factors. But really, this is about awareness. It's not about panic.
I would say one of the problems with increased screening or going to MRI or ultrasound is that both of those have a fairly high false positive rate, so you may wind up getting biopsies or needle biopsies or open biopsies or other technology that you
really don't need. I think if you told you have dense breasts and there's some suspicious areas at all, my recommendation, and actually my wife went through that is I would find a breast surgeon, a surgeon who specializes just in breast health, and see them and follow
their guidance. They're the people that have the most experience at trying to figure this out, especially if there's high density in the breast, and also some area that looks suspicious, I think your your best move at that point would be to go see a breast surgeon and let them help you decide what should be your next step.
And I would also say that if the radiologist reads your mammogram and says you have dense breasts and area with increased density that they recommend further imaging. The typical next step
is an ultrasound. And I would also say, don't panic on that, because about 50% - 40 to 50% of women who have their first mammogram are going to end up also getting a breast ultrasound to further look at things, and it's just that initial screening where they're getting a good feel for what is going on with your breast density and how to proceed in the future. So I know that second image can be very anxiety provoking for people, but I would think of it as, again, just it's a heads up.
You're learning your breasts at that age 40. Everybody's figuring out exactly what screening they need to do, and it's nothing to panic about. Our technology has made such great strides that we look for and we find things, and we cause a little bit of anxiety, sometimes over things that really are just normal.
Sometimes a lot of anxiety. There are women who have had prophylactic mastectomies because it just made them so anxious not knowing for sure whether they they had a cancer brewing or not. So we want to try and avoid that if we can.
So do your due diligence, but not any differently than you would whether your doctor said dense breasts or not?
Yeah, and don't be afraid to talk to your doctor about it. Actually, don't be afraid to ask to talk to the radiologist. There are states, many states now, that mandate that a radiologist report to women if they deem that she has dense breasts, and, you know, recommending further studies, but you shouldn't hesitate to talk to them about it. Talk to your providers, talk to your radiologist.
Yeah, and I would also say, talk to your family. So I think you'd be surprised. If you turn 40, you get your first mammogram, they say you have dense breasts, no matter the size of your mother or sisters, even if they're bigger than you, smaller than you, ask them about it, because you may find out they've had dense breasts their whole life as well. And so it can put your mind at a bit of ease too, as there is just a genetic component to it.
What about other websites or information out there? Especially with as common as this is, I would hope that if a woman did want to learn a little bit more for themselves, where could they go?
So the Mayo Clinic always has wonderful resources that are written in layman's terms, and you can even just search "dense breasts Mayo Clinic," and it will bring up some good resources and answers to commonly asked questions. The CDC and the American Cancer Society, they also have great resources. There's also a breast cancer organization that provides a lot of answers to these questions, or some of the most commonly asked questions. So all of these are resources
that you can look into. And I'm guessing Beth, we can put those in the show notes.
Absolutely we can. Would you add anything to that, Doug?
No, I would encourage women to get their screening. Don't be afraid. And if you get the report that you have dense breasts, as Tiffany said, don't be afraid. Talk to your doctors, talk to your family, and proceed. You don't need to panic over it.
Be an empowered and active patient, which is a message we have on here all the time. So this is just another example of that.
Yes, don't be afraid to speak up.
Exactly. Well, thank you so much both for being here today. We appreciate both of your time. And yes, as Tiffany said, we will definitely get some resources along with this episode so you can learn more, if you would like. And if you have a question for Dr. K for either of the Dr. K's, please email us at QandAwithDrK@mpqhf.org and we'll have that email address with this episode as well, and we answer all those questions anonymously. Thanks so much. Be well.