Breast Density: Optimisation of Communication and Clinical Care

Knowledge is often regarded as power; however, the precise extent of knowledge required to wield such power remains undefined. In recent years, knowledge about breast density has become a topic of significant debate within the academic and medical communities. This discussion has gained particular prominence in Australia. Breast density, also known as mammographic density, appears as the white and bright areas on a mammogram. The greater the proportion of these white and bright regions, the higher the breast density. Breast density is inversely associated with age and body mass index. Breast density is clinically significant as it is both an independent risk factor for breast cancer and a potential impediment to tumour detection in mammograms. Given these considerations, many argue that breast density information should be disclosed to women during routine screening mammograms. However, there is concern that providing this information, particularly to women with high breast density, could lead to confusion, heightened anxiety and unnecessary additional test . Reflecting this apprehension, BreastScreen Australia has opted not to include breast density notification as a standard component of its screening program. Their position is grounded in the limited availability of research conclusively demonstrating that breast density notification does not cause harms such as anxiety. Without sufficient knowledge about breast density among women, the potential for anxiety following breast density notification remains a valid concern. Additionally, an effective and reassuring communication strategy is pivotal in clinical care that reduces anxiety successfully. However, there is no structured guideline for breast density communication in Australia. This research aimed to (1) evaluate breast density knowledge of South Australian women, (2) assess the psychological impact of breast density notification, and (3) explore conversation themes in breast density telehealth consultations between breast surgeons and women attending hospital-based breast cancer screening. This cross-sectional mixed methods study was conducted in women undergoing breast cancer screening at The Queen Elizabeth Hospital Breast/Endocrine outpatient department in South Australia with approval from the Central Adelaide Local Health Network Human Research Ethics Committee. In Study 1, knowledge about breast density of South Australian women undergoing a screening mammogram was assessed by administering a questionnaire. Two-thirds of the participants were familiar with the term ‘breast density’ and more than half had ‘some knowledge’ about breast density. This study identified that prior breast density notification, awareness, younger age, and English as the language spoken at home were associated with increased breast density knowledge. However, the study also showed widespread misconceptions including the misunderstanding that breast density can be determined by touch. Interestingly, eighty two percent of women expressed their interest to know their own breast density. In Study 2, the psychological impact of breast density notification was assessed using the State and Trait Anxiety Inventory (STAI) tool, which is a validated method used across the world for health-related anxiety measurement. State anxiety determines how the subject feels after receiving the disease-related distressful information; for this study, it is breast density information. On the other hand, trait anxiety determines how the subject generally feels. Therefore, the STAI tool assesses anxiety related to the health event on the backdrop of the subject’s general anxiety status. This research suggested that state anxiety was not different between women notified they had dense breasts compared to those who were notified of non-dense breasts. There was also no significant difference in trait anxiety. This study also asked women how they felt after being told their breast density. Eighty two percent of women reported positive or neutral reactions to breast density notification, with 17% of reactions being negative. In Study 3, telehealth consultations between surgeons and patients who had been notified of their breast density were recorded and qualitatively analysed. Central themes of the consultation were addressing breast density knowledge gaps, placing breast density into the context of the patient’s individual circumstance, providing reassurance, and exploring optimal breast screening management pathways. A key takeaway from this study was that doctors who initiated conversation with an open question such as “What questions came to your mind when you got your breast density letter?” were most effective in identifying patient misconceptions and inviting discussion about patient concerns. These findings will help healthcare practitioners to understand the type of dialogue and the diversity of concerns patients raise during breast density consultation. Overall, this research identified that the general understanding of South Australian women about breast density is quite low. Despite this, they wish to know their own breast density to participate in a shared-decision making about their breast cancer screening. In notifying women of their breast density, consideration of women’s knowledge, range of experiences, and circumstances is required. Existing misconceptions can be addressed in public awareness campaigns and in conversations between healthcare professionals and women. Negative reactions to breast density information can be mitigated through co-design of communication strategies with consumers and clinicians. The research in this thesis can be used to support development of future public awareness campaigns, communication strategies, and clinical guidance for management of women with high breast density. To support General Practitioners dense breasts. There was also no significant difference in trait anxiety. This study also asked women how they felt after being told their breast density. Eighty two percent of women reported positive or neutral reactions to breast density notification, with 17% of reactions being negative. In Study 3, telehealth consultations between surgeons and patients who had been notified of their breast density were recorded and qualitatively analysed. Central themes of the consultation were addressing breast density knowledge gaps, placing breast density into the context of the patient’s individual circumstance, providing reassurance, and exploring optimal breast screening management pathways. A key takeaway from this study was that doctors who initiated conversation with an open question such as “What questions came to your mind when you got your breast density letter?” were most effective in identifying patient misconceptions and inviting discussion about patient concerns. These findings will help healthcare practitioners to understand the type of dialogue and the diversity of concerns patients raise during breast density consultation. Overall, this research identified that the general understanding of South Australian women about breast density is quite low. Despite this, they wish to know their own breast density to participate in a shared-decision making about their breast cancer screening. In notifying women of their breast density, consideration of women’s knowledge, range of experiences, and circumstances is required. Existing misconceptions can be addressed in public awareness campaigns and in conversations between healthcare professionals and women. Negative reactions to breast density information can be mitigated through co-design of communication strategies with consumers and clinicians. The research in this thesis can be used to support development of future public awareness campaigns, communication strategies, and clinical guidance for management of women with high breast density. To support General Practitioners in breast density consultations with their patients, comprehensive educational programs should be developed. These programs should focus on the clinical significance of breast density, evidence-based supplemental screening options, and effective communication strategies.

Author dc:creator

• Bhattacharjee, Avisak

Advisors dc:contributor.advisor

• Ingman, Wendy
• Turnbull, Deborah
• White, Sarah J.

• breast cancer risk
• breast cancer screening
• breast density
• knowledge
• mammographic density
• anxiety
• surgeon-patient consultation

Language dc:language.iso

en

Handle dc:identifier.uri

https://hdl.handle.net/2440/145261

OAI identifier oai:identifier

oai:digital.library.adelaide.edu.au:2440/145261