Dense Breasts: Avoiding Needless Biopsies

Patient Expert

Recent research shows that women with dense breasts are at increased risk of breast cancer. As with any group at higher risk, it's recommended that these women pay special attention to their breasts - both by checking regularly for new lumps, and by receiving periodic cancer screening.

Problem is, dense breasts are also very difficult to successfully screen; and a challenge when it comes to self-exams. Thus there's a higher probability that women with dense breasts will undergo a biopsy, or multiple biopsies - most or all of which will be negative, resulting only in scars, pain, and stress.

Could a combination of ultrasound and a newly revived technology, elastography, save these women from needless biopsies and their accompanying anxiety?

A friend of mine, call her Jen, is a younger woman who's lithe, fit, and athletic. She's never sick, avoiding the flu and colds most of us experience as a matter of course.

However, Jen has one health issue that drives her crazy: dense breasts. It's not the breasts themselves that she dislikes; they're perfect for her slight, muscular frame. But she's had so many cancer scares, and so many biopsies, that she's at her wit's end.

"I swear, next time I'm going to tell them just to cut the darned things off," she confessed to me. "If they keep taking out chunks with every biopsy, pretty soon there's not going to be anything left, anyway."

Jen's story isn't unusual. Many small-breasted women are identified as having dense breasts, a clinical term referring to the percentage of fat vs. glandular and connective tissue in a woman's breast.

It's not something you can judge on your own; only a radiologist can make the call. And with breast density now recognized as a factor in breast cancer risk, more and more women are asking the radiologist who reads their screening mammogram to provide an assessment of their breast density, along with the mammogram results. Statistically, up to 40% of women have dense breasts at some point in their lives.

So, if you find out you have dense breasts, what should you do about it?

First, understand that your mammograms will be harder for the radiologist to read. Typically, a mammogram identifies breast abnormalities by very simply looking at light/opaque and dark/clear areas in the breast; fat or fluid are dark/clear, while connective and glandular tissue is light/opaque.

Women whose breasts contain a significant amount of fatty tissue provide the radiologist with a clear field of view; anything unusual (a tumor, for instance) will stand out starkly: white on black.

But a mammogram of a dense breast is much less clear. With a background of varying shades of white and gray, it's difficult to spot any unusual lighter-colored area - e.g., a potential tumor.

Likewise the breast self-exam. If you're large-breasted, it's very obvious when a new lump is suddenly palpable. But if you're small-breasted, chances are your breasts typically feel lumpy and "gnarly;" it's difficult if not impossible to pick out any new lump - particularly if it's small.

So, given that the typical once-a-year mammogram starting at age 40 or 50 might not be appropriate for you and your dense breasts, what are your options?

First, make sure you're getting a digital (rather than film) mammogram. Most facilities have switched to digital, as it's more sensitive; it's better at picking out potential trouble areas.

Second, ask your doctor about alternate screening methods. An ultrasound can reveal whether or not the questionable area on your mammogram is a cyst; but it can't go further than that. If it's not a cyst, but a solid lesion, your doctor may be thinking biopsy.

Before going the biopsy route, ask your doctor about combining another ultrasound with elastography, a type of screening that's often given concurrent with ultrasound; in fact, many ultrasound machines have elastography capability (it's a simple software add-on), if the radiologist directs the screening tech to use it.

Problem is, not many choose to access this alternate technology; it wasn't very accurate when it first came out. Now, though, research has shown it's much better than the original technology in determining which solid masses might be cancerous, and which are simply breast or scar tissue, or a non-cancerous tumor (fibroadenoma).

How does it work? Simply put, it measures how hard or soft the mass in question is. Cancerous tumors tend to be harder than other breast tissue; elastography determines how "squishable" the tissue is, and compares it to known standards for cancer.

The FDA hasn't yet approved elastography as a screening tool; but some radiologists are using it in conjunction with ultrasound, where it's especially helpful in determining whether or not a biopsy is warranted. If neither a mammogram nor ultrasound can either rule out cancer, nor create a really strong case that it's present, then elastography can help guide the decision: biopsy vs. "watchful waiting."

If you're a woman who's faced multiple biopsies, keep this new tool in mind. Or if you've been through the wringer with inconclusive breast cancer screening tests, and your GP is recommending biopsy, but the radiologist says "we'll just check it again in 6 months" - ask about elastography. This one last test just might give you the information you need to make a very tough decision.


McCarthy, A. (2009, April 29). Arrs 2009: Breast elastography accurately diagnoses malignancies. Retrieved from Appendix  A breast cancer technology overview. (2005). Retrieved from