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Beth Israel Deaconess Medical Center Harvard Medical School Boston MA, 02215
In their recent article, Venta et al. [1] state, "The breast parenchymal density distribution in our study (i.e., 4% fatty, 51% mixed, 43% dense, and 2% extremely dense) is similar to that reported in other studies...." I have always found it self-defeating to have four standard categories of breast density in the Breast Imaging Reporting and Data System (BI-RADS) reporting system [2] when many mammographers classify 90-95% (94% in this article) of the mammograms they interpret into only two of these groups.
Virtually every mammographic report generated in the United States, and to a large extent throughout the world, is classified into one of the these four density categories. Their primary purpose is not descriptive but rather "to help indicate the relative possibility that a lesion could be hidden by the normal tissues" [2]. Unfortunately, the actual appearances of the breast parenchyma, and the corresponding risk category, can frequently not be pigeonholed into one of the standard BI-RADS descriptors such as "scattered fibroglandular densities" or "heterogeneous dense" [2].
Because categorization of breast density is relatively arbitrary, and most biologic data fall into bell-shaped curves, I propose to my residents that the four categories of parenchymal density be approximately: 20% fatty, 30% slightly dense, 30% moderately dense, and 20% dense or extremely dense. It may be true that breast density is greater in svelte southern California than in the more buxom Midwest. However, I believe each mammographer, whatever his or her breast imaging clientele, should attempt to achieve a more balanced use of these four breast density categories. I further hope that future revisions of BI-RADS will continue having the categories stress the suitability of the breast parenchyma for mammographic interpretation while de-emphasizing the corresponding rigid descriptors.
References
Lynn Sage Comprehensive Breast Center Northwestern University Medical School Chicago, IL 60611-2923
Dr. Hall makes an interesting point about the limitations of the four Breast Imaging Reporting and Data System (BI-RADS) breast density categories for capturing breast density information [1]. The preponderance (94%) of cases in our study [2] were placed in the middle two categories of breast density. This finding is similar to other studies that have used the BI-RADS breast density ratings. Table 1 compares our diagnostic study's breast density results to the recently published digital screening study by Lewin et al. [3], involving 4,945 women who had both digital and screen-film mammography.
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Our purpose in including BI-RADS breast density categories was to describe the breast density of our study population to readers in a relevant way. Although we agree that the distribution of breast densities based on BI-RADS density categories is uneven, we are not conviced that the practice advocated by Dr. Hall of forcing the distribution to a fixed fraction in each category is helpful. If Dr. Hall's approach were applied at different sites or in different study populations, it could mask true differences in breast densities caused by geographic, age, ethnic, or study-group differences.
Digital mammography affords a relatively simple way to estimate breast density quantitatively on each image [4]. Rather than relying entirely on a radiologist's assessment of breast density using the four BI-RADS density categories it might be useful in future digital software to provide a breast density assessment of each image, just as the Senographe 2000D system (General Electric Medical Systems, Milwaukee, WI) currently provides an estimate of mean glandular breast dose for each image. This digital information would eliminate the need to restrict the assessment of breast density to four categories.
References
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This article has been cited by other articles:
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  F. M. Hall and K. E. Martin, MD Mammographic Density Categories Radiology, October 1, 2007; 245(1): 300 - 302. [Full Text] [PDF]
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F. M. Hall, T. M. Kolb, J. Lichy, and J. H. Newhouse Screening Breast US [letter] * Dr Kolb and colleagues respond: Radiology, May 1, 2003; 227(2): 607 - 609. [Full Text] [PDF]
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 F. M. Hall, M. S. Soo, E. L. Rosen, and J. A. Baker Negative Predictive Value of Breast Imaging in Patients with Palpable Lesions Am. J. Roentgenol., October 1, 2002; 179(4): 1073 - 1074. [Full Text] [PDF]
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F. M. Hall and S. S. Kaplan Screening Breast US * Dr Kaplan responds: Radiology, September 1, 2002; 224(3): 930 - 932. [Full Text] [PDF]
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