Dense Breast

Doctor, they didn't detect cancer on my mammogram!

We have heard this phrase multiple times from patients who come for regular screenings after breast cancer treatment.

Is it really possible to miss it? Yes, it is. Moreover, breast cancer not associated with microcalcifications is often not visible in dense breast tissue (up to 50% of tumors less than 2 cm are not visible on mammograms in breasts with density 3/4).

So, I go for mammograms every 2 years and think everything is fine, but something might be growing there unnoticed?

Let's break it down.

Breast density plays a crucial role in mammography's sensitivity (ability to detect abnormalities or cancer). What does this mean? The "denser" the breast (where fibroglandular tissue predominates or dominates, "hiding" small tumors), the less chance there is to detect a tumor at an early stage – when it is still within the milk ducts (in situ) or when it has passed beyond the ducts (invasive) but has not reached a size of 1 cm (then the risk of lymph node metastasis is <1%, and 98% of women have a chance of complete cure).

Is there a chance to detect tumors at an early stage? I regularly perform breast self-exams!

On average, palpation (self-exams) can detect tumors of 2-3 cm, which is not considered early diagnosis and does not lead to increased life expectancy. So, is mammography the answer? With the introduction of mammography, there was a real opportunity to reduce breast cancer mortality. Mammography's advantage lies in its reliable detection of microcalcifications, which can be an indicator of cancer, as well as the detection of nodular formations. However, if the breast tissue is very dense (rated as 3 or 4), it becomes significantly more challenging, or even impossible, to identify tumors not associated with microcalcifications. The sensitivity of mammography in women with low-density breasts (90-98%) significantly drops in the case of dense breasts (35-50%).

What if we add ultrasound (US) to mammography?

In that case, we slightly increase the chances of detecting breast cancer in dense breasts, but this does not solve the "dense breast" problem.

Is there still a way to detect tumors in dense breast tissue?

This problem has been partially addressed with tomosynthesis – a layered examination of breast tissue, similar to computed tomography. Tomosynthesis makes it possible to identify nodular formations or changes in the normal architecture of glandular tissue. But here, too, there is a significant limitation: to detect a tumor with tomosynthesis, the presence of adipose (fatty) tissue around the tumor is required. In cases of very dense breasts (rated as 4), this fatty tissue is practically absent, making diagnosis significantly more challenging.

So, is there no solution, even with the most modern methods?

Modern science has found a solution to this problem, and it's ANGIOGENESIS! Don't worry; you won't lose consciousness. You'll understand it all now. Angiogenesis is the formation of new blood vessels that nourish a tumor because it grows rapidly and needs "nutrition." In the past, attempts were made to measure the temperature above the tumor using thermography, but it was a highly nonspecific examination. Much better results have been achieved with the intravenous injection of a contrast agent and its accumulation in the tumor. In the 1980s, contrast-enhanced breast MRI emerged as the most sensitive method for early breast cancer diagnosis. Specifically, Professor Uwe Fischer from Göttingen was one of the pioneers of this revolutionary method. Thanks to technical advancements, contrast-enhanced breast MRI has become the most sensitive method for early breast cancer diagnosis. Professor Fischer demonstrated a significant increase in the detection of carcinomas by MRI in high-risk patients (92-99%) compared to combined mammography and ultrasound (63-68%), as breast density is not a limitation for MRI (EVA study and (HIB-CRIT)). There is data that even in patients without an elevated risk, MRI detects twice as many tumors compared to non-contrast methods. Later, spectral mammography with contrast became available to detect angiogenesis in tumors.

In conclusion, if you have very dense breast tissue, it is essential to undergo early diagnosis with MRI!