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Breast Center

Henda's Law- Breast Density

Supplemental Screening for Women with Dense Breast Tissue and Increased Risk


The 2011 Texas Legislature passed House Bill 2102 which became effective September 1, 2011. The law is informally known as Henda’s Law, named after Henda Salmeron, a Dallas realtor and breast cancer survivor who was instrumental in organizing the effort to draft and pass the law in Texas. This law, in effect, requires us to include your breast density grade in the report to your physician and to provide you a copy of the following notice:

"If your mammogram demonstrates that you have dense breast tissue, which could hide abnormalities, and you have other risk factors for breast cancer that have been identified, you might benefit from supplemental screening tests that may be suggested by your ordering physician.

Dense breast tissue, in and of itself, is a relatively common condition. Therefore, this information is not provided to cause undue concern, but rather to raise your awareness and to promote discussion with your physician regarding the presence of other risk factors, in addition to dense breast tissue.

A report of your mammography results will be sent to you and your physician. You should contact your physician if you have any questions or concerns regarding this report."

We will include the above statement on your mammography result letter. The report to your physician will include your breast density so that he may share this information with you.

For consistency, the American College of Radiology has 4 grades of breast composition to describe the breast density of all patients using the following patterns:

  • Grade 1: The breast is almost entirely fat (less than 25% glandular)
  • Grade 2: There are scattered fibroglandular densities (approximately 25-50% glandular)
  • Grade 3: The breast tissue is heterogeneously dense, which could obscure detection of small masses (approximately 51-75% glandular)
  • Grade 4: The breast tissue is extremely dense. This may lower the sensitivity of mammography (greater than 75% glandular)

For the purpose of this law, women with breast grades 3 or 4 are considered to have “dense breast tissue”.

The fact that dense breast tissue lowers the accuracy of the mammogram has been recognized for several decades, and supplemental screening of high-risk women with difficult mammograms has been occasionally provided to some patients for many years. This practice, however, has never been formalized nor uniformly practiced by mammography facilities. For women with an average lifetime risk of breast cancer, undergoing supplemental screening is not considered the standard of care, even if they have dense breast tissue. It was Ms. Salmeron’s belief that women deserve to be directly informed if they have dense breast tissue and be given the opportunity to be proactive in their choices regarding the early detection of breast cancer. So, you may want to discuss your risk factors with your physician.

Mammogram Image

Limitations of Mammography

Contrary to popular notions, the majority of cancerous breast tumors are relatively slow-growing and detectable at an early stage in women who are undergoing a regular, annual mammogram- even in those with dense breast tissue. Some tumors, however, may simply be very small at the time of the mammogram or lacking in distinct characteristics, thereby allowing them to be obscured by overlying breast tissues. If these undetected tumors are fast-growing, they may well be detected on breast self-examination or on a clinical breast exam by your doctor before the next annual mammogram is due. If slow-growing, they may be detected on the mammogram a year or two later, but the opportunity for the earliest detection will have been lost.

Supplemental Screening

One method of supplemental screening is breast MRI, which is typically recommended in women who have tested positive for one of the “breast cancer genes” (BRCA-POSITIVE), regardless of their breast density. However, MRI may prove too expensive for screening women who present with dense breasts as their only elevated risk, and it has not been shown to be beneficial in randomized controlled trials in this group of patients.

More recently, a major study suggested that breast ultrasound can improve the detection of early breast cancer in women with dense breast tissue.

Studies indicate that both breast ultrasound and MRI have a significant rate of “false-positive” examinations which may result in the need for a needle biopsy or other invasive procedures at substantial cost. False positives occur in mammography, as well, but the rate of false positives is dramatically reduced by the advanced training, focus, and exam volume of the radiologist interpreting the examination. False positives in both MRI and breast ultrasound are typically higher than for mammography, even when performed by experienced professionals.