ACR Statement on Reporting Breast Density in Mammography Reports and Patient Summaries

The American College of Radiology (ACR) is a vigorous advocate of quality breast imaging. Before there was a federal mandate for breast imaging accreditation, the College established a voluntary mammography accreditation program promoting standards for quality assurance and quality control. Our mammography accreditation program was used as the model for the Mammography Quality Standards Act (MQSA).The ACR has supported the MQSA enactment and subsequent reauthorizations –including the requirement for patient notification through summary letters. The ACR has developed voluntary accreditation programs for other breast imaging modalities that are not covered by the MQSA. The ACR supports annual mammography screening starting at age 40, based on strong scientific evidence and in agreement with the guidelines of the National Comprehensive Cancer Network. We have invested considerable effort to encourage women and their health care providers to utilize screening to save lives.

The ACR recognizes that breast density has an impact on mammographic screening.The ACR’s BI-RADS^® lexicon describes four categories of breast parenchymal densityand instructs radiologists to include this density information in the medical report. It iswell known that greater breast density results in lower sensitivity for mammography. Byincluding this information in the medical report, the referring health care provider isgiven a general idea of the likelihood that cancer will be detected or missed based onthe parenchymal pattern. The ACR would support an FDA mandate that information onbreast parenchymal density be included in the mammography report.

The ACR supports and promotes the practice of patient education. As such, werecognize that density information included in the lay summary women receive fromtheir mammography examination may be helpful in encouraging an informed dialogueon this topic between the patient and her physician. The ACR believes it is important forwomen to understand the following about breast density:

• The assessment of breast density is subjective and, therefore, variable. When the same mammogram is interpreted by a different physician or by the same physician on different occasions, differing density can be reported. This does not indicate a problem with the mammogram or the interpreting physician; it is a common occurrence.
• Density itself is a risk factor. Women with dense breasts have approximately 1.5 times higher risk than the average woman. (This number is variable in the literature because of attempts to compare the far ends of the spectrum – the extremely dense population with those who have entirely fatty breasts – instead of a comparison with the average population, as with most other risk factors.)
• Supplemental screening should be a thoughtful choice after a complete risk assessment, not an automatic reaction to breast density itself. We encourage women to seek information from their doctors for a more complete discussion.
• Even women with fatty breasts may have breast cancer undetected by mammography. High-risk women should not be complacent and forego recommended Screening MRI because they have fatty breasts.
• Appropriate supplemental screening should be reimbursed by insurers, and we urge Congress and payers to ensure that this happens. Otherwise, there may be an unfortunate disparity between women who can afford to pay for the additional screening exam and those who cannot.

The ACR recommends that the interest of the patient be placed first. The ACR is happy to work with legislators, regulatory agencies and patient groups to arrive at evidenced based imaging policies which save and extend lives.