Are you dense? The implications and imaging of the dense breast

Mammography relies on a visual interpretation of imaging results that is often confounded by dense breast tissue. Dense tissue affects the ability and accuracy with which the radiologist is able to detect cancer. Dense tissue may mask the presence of a breast cancer, and breast density is well recognised as an independent risk factor for the development of breast cancer. In the dense breast, detected cancers tend to be larger, more often lymph node positive and of a higher stage than those diagnosed in fatty tissue. The incidence of tumour multifocality and multicentricity is higher, decreasing the chances for breast conserving treatment. The literature convincingly supports the use of supplemental imaging modalities in women who present with increased breast density. There are clear advantages and disadvantages to each set of diagnostic imaging tests. However, there is no simple, cost-effective solution for women with dense breasts to obtain a definitive detection status through imaging. Suggestions are put forward as to what supplemental imaging choices should be included for the imaging of the dense breast with reference to the current South African setting. Use of supplemental screening modalities should be tailored to individual risk assessment. In a resource-constrained environment, international recommendations may need to be adjusted.