Over the last several years, research has helped draw the link between breast density and breast cancer. Patients with dense tissue are at higher risk of the disease and may benefit from secondary screening modalities, due to the possibility that dense tissue will mask a tumor on conventional mammogram exam.

This has led to dense breast notification (DBN) laws aimed at raising awareness among patients so they can take better control of their health – but are these efforts achieving their goals? Nancy R. Kressin, professor of medicine at Boston University Medical Center, has studied their success and says there’s still work to be done.

HCB News: Can you tell us about the origins of DBN laws?
Nancy R. Kressin: Recognizing that many women were not aware of the risks of dense breasts, advocates worked with legislators to implement state legislation requiring written notification of a patient’s breast density. As of 2021, 38 states had DBN laws. This legislation aims to increase women’s awareness about personal breast density and its impact on mammography and breast cancer risk. It also aims to facilitate informed decision-making by encouraging discussions with providers about personal breast cancer risk and the appropriateness of supplemental screening.

HCB News: Can you share some examples of how these notification laws are different in different states?
NK: Per a paper we published in JAMA in 2016, all DBNs we reviewed at that time mentioned masking bias, 17 (74%) mentioned the association with increased cancer risk, and 15 (65%) mentioned supplemental screening as an option, advising women to consult their physician. Of 15 DBNs requiring mention of supplemental screening, six informed women that they might benefit from such screening and four mentioned specific modalities.

HCB News: You recently looked at how breast density awareness compared among women in states with notifications and states without. What did you find?
NK: Multivariate regression models adjusted for covariates indicated that women in notification states were 1.5 times more likely to receive density information while older, lower income, lower literacy, Black and Asian women were less likely. Overall, only 39% of women discussed density with providers; women in notification states were 1.75 times as likely. Older and Asian women were less likely to have spoken with providers; women with high literacy or prior biopsy were more likely. State legislation status was not associated with differences in density knowledge, but Hispanic, lower income, or low health literacy women had less knowledge regarding density’s masking effects; older women were more knowledgeable.

HCB News: Do we know why breast density notifications are not more effective?
NK: Our prior paper in JAMA, which reported textual analyses we conducted on various states' DBNs, found that DBNs' readability levels ranged from grades seven to 19.4 (mean, 11.1), most exceeding the recommended readability level (grades seven to eight); about 20% of the population reads below a fifth grade level. Only three states’ DBN readability level was at the eight-grade level or below, and some of the highest readability levels occurred in states with the lowest literacy levels. These findings suggest that DBNs are hard to read and/or understand for some women.

HCB News: What role can healthcare providers play in supporting breast density awareness among their patients?
NK: In other research led by my colleague Dr. Christine Gunn, we have found that providers are themselves not well-informed about breast density. So, for starters, it seems that they need more education about breast density and the associated risks. Then, with this information, they can help to educate their patients.

HCB News: Are there other opportunities, more broadly, to improve breast density awareness across the country?
NK: Yes, there is an opportunity to improve health education about breast density in general and especially for women with low literacy, through decision aids, and health education materials. It seems that more targeted approaches are needed to achieve more equitable knowledge and access to information, in order to alleviate existing disparities.