Cathy Esposito, of Trumbull, regularly had mammograms to test herself for breast cancer and for years they came up negative.
In 2006, Esposito found a lump in her breast -- about a month after having a mammogram that came back negative. Esposito has dense breasts, which medical experts said can camouflage cancer.
At that time, she said, it wasn't common for women like her to receive additional screening, such as ultrasound, which is more sensitive and more likely to pick up possible abnormalities.
It wasn't until she found the lump and demanded more screening that Esposito received an ultrasound.
"The ultrasound is what really showed the mass," said Esposito, 54.
Three years after her diagnosis, Connecticut became the first state to enact dense breast legislation requiring that women be informed of their breast density when they receive their mammography report, and mandating that insurance companies provide coverage for the screening.
Today, additional screenings are commonplace, as evidenced by TV personality Joan Lunden's recent announcement that she has breast cancer, which was discovered via ultrasound. The former "Good Morning, America" host, like Esposito, had dense breasts -- meaning the tissue is comprised of less fat and more fibrous connective tissue. A recent mammogram missed the cancer, but it was later picked up in an ultrasound.
Mammograms are problematic in women with dense breast tissue, because they present a black-and-white image of the breast, said Dr. Anees Chagpar, director of the breast center at Yale-New Haven Hospital's Smilow Cancer Hospital. Dense tissue reads as "white" in the image, as do possibly cancerous mass, she said. "It's a white-on-white image," Chagpar said.
Dr. David Gruen, director of women's imaging and co-director of the breast care program at Stamford Hospital, echoed Chagpar's statement. Fatty breasts, meaning those that are not dense, make it relatively easy to find possible cancers via a mammogram. "Fatty breasts are like a cloudless sky," Gruen said. "But looking at mammogram of a dense breast is like looking at a cloudy sky."
Unlike mammograms, ultrasounds use sound waves to make images of the breasts, and gives a clearer differentiation because breast tissue and possible abnormalities. Research has shown that, in women with dense breasts, ultrasounds combined with mammograms pick up more cancers than mammograms alone.
But doctors were quick to point out this method isn't infallible.
"This doesn't mean everyone should run out and get an ultrasound," Chagpar said.
For one thing, although ultrasounds improve breast cancer detection, there's no evidence to suggest they decrease patients' risk of breast cancer death. That's part of the reason why some in the medical community objected to breast density legislation, said Dr. Barbara A. Ward, medical director of Greenwich Hospital's breast center.
"There were a lot of physicians who felt `Why are legislators telling us what to do if it's not data driven?' " she said.
Another drawback is that, although insurance covers the cost of breast ultrasounds, not all cover the entire cost. Many only cover the cost after a deductible is satisfied.
And, as with most methods of breast cancer screening there are concerns about false positives. Sometimes mammograms, ultrasounds and other screening methods pick up abnormalities that ultimately turn out not to be cancer. This can cause fear and anxiety in some patients, and may lead to unnecessary breast biopsies.
Doctors agreed that ultrasounds in particular can lead to false positives, but that doesn't mean they're not worthwhile for some women, said Steven Cohen, director of ultrasound for St. Vincent's Medical Center, Bridgeport Hospital and Advanced Radiology Consultants.
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