The “Risk” behind Breast Density

This article follows in the footsteps of my most recent submission titled, “Breast Density: The Value behind the Analytics” which brought focus to #BreastDensity Reporting Laws and the quantitative and qualitative analytics needed for advanced breast imaging screening.

Within healthcare, we have become accustomed to legislators and insurance payers dictating the care we as a population receive. One specific example is Advanced Imaging Mammography screening for those individuals classified as having dense breasts. For those women with #densebreast, not only is a qualitative based analytical screening needed for insurer/payer coverage, an accompanying hereditary risk based screening is also required.

As part of the documentation needed to support advanced imaging, healthcare providers rely on many tools to estimate a woman’s risk of developing breast cancer. There are risk assessment tools for women who are not suspected to be at risk of having hereditary breast cancer. The two most common tests are: the Gail Breast Cancer Risk Assessment Tool, which happens to be the most widely used tool for estimating a woman’s 5-year and lifetime risk of developing invasive breast cancer; and the Hall Detailed Breast Risk Calculator, a breast cancer risk assessment tool that includes some risk elevating and risk-lowering factors not included in the Gail Tool.

Additionally, there are Risk Assessment Tools for Women who are suspected to be at risk of having hereditary breast cancer. The two most common tests used are: the Myriad Risk Table, a simple table that is used to estimate the probability of having a BRCA1 or BRCA2 mutation based on personal and family history of breast and ovarian cancer; and the BRCAPRO, the most widely accepted tool for determining the lifetime risk of breast, ovarian, colorectal, endometrial, melanoma, and pancreatic cancer based on your family history and family pedigree.

The uses of breast cancer risk assessment tools play an integral part of a women’s health program and organizational strategy in preventive medicine or #populationhealth. However, incorporating risk-based assessments into any practice workflow can be challenging, as it constitutes additional time from staff to oversee the interview process and subsequent consulting.

For those patients who classify as having dense breasts, the risk assessment is an essential component to obtaining payer approval for advanced MRI or Ultrasound breast imaging. Therefore, having an efficient workflow in place to expedite payer approval for additional imaging is necessary financially, but can also significantly impact the psyche of patient having to wait for insurer approval for advanced imaging.

Upon researching available “technology solutions” to address clinic workflow and efficiency for payer approval, I happened to come across Hughes RiskApps@hughesriskapps This is an open-source software platform for the collection of familial history, risk assessment, and Clinical Decision Support (CDS) package, geared toward improving clinic workflow and quality of care in identifying the high-risk population. Through the use of a patient friendly tablet-based tool within the breast imaging suite or a web-based platform that can be accessed within the privacy of a patient’s home; an opportunity for operational efficiency is present.

The risk-based calculations are based upon using the industry standard methods (Tyrer Cuzick, BRCAPRO, Claus), in turn allowing for expedited decision making for appropriate MRI based screenings. The financial benefit of using such a program is increased approval for MRI Breast Imaging for High-Risk patients. It is important to keep in mind the term high-risk as most payers follow the below approval process.

  • Insurance may not cover the cost of a screening breast ultrasound or MRI for women at average risk for breast cancer.
  • Screening breast ultrasound and/or MRI should be covered for women at high risk for breast cancer.

So how does the Hughes RiskApps as well @VolparaDensity contribute to the overall picture of Breast Density, High-Risk Breast Cancer, and Breast Density Legislation? One of the reported fears by some critics in the field is how a woman is notified of her breast density and the appropriate verbiage used. They feel women may receive the information in less than ideal circumstances (a general notification letter), which can lead to increased anxiety, as well as additional medical procedures. If clinician’s utilize the quantitative and qualitative data derived from both sources, they could provide the necessary clinical information in an “effective notification letter,” providing the recommended next steps per guidelines for women to consider.

The Breast Density Legislation being brought forward from groups like @areyoudenseadvo, advocate for and support State and Federal legislative and Regulatory efforts to standardize the communication of dense breast tissue to women, as well provide access to reliable breast screening technologies for women with dense breast tissue. As it stands now, the general standard of communication lies within “notification letters”, some of which vary significantly in content and detail.

Now is the time for our clinicians to come out of the dark and into the light. Incorporate a clinical workflow strategy based upon devoting time for direct communication at point of service; provide that level of compassion and trust with your patient regarding their personalized risk of breast cancer occurrence; and discuss the available options for them to consider.

As always, I appreciate your feedback and comments and be reached at and on Twitter @uscaspecialist.