There’s a type of breast tissue that can hide cancer. Here’s what to know about it.
An interview on dense breast tissue. Plus: What’s a “formulary”? + What rights do you have to your medical records?
Welcome to Doing Well. Today:
An interview on breast cancer screening
Health news we’ve found useful this week
Word of the week: formulary
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We Asked: What are dense breasts, and how do they affect cancer risk?
Breast cancer is the second most common cancer among women in the U.S., behind skin cancer—around 1 in 8 women will face an invasive breast cancer diagnosis in her lifetime. Thankfully, breast cancer survival rates have improved significantly due to advances in screening and treatment, and when caught early, breast cancer is very treatable.
But some breasts have more of a certain tissue that can make it harder to detect cancer, even if a woman is going in for recommended screenings. This was the case for JoAnn Pushkin, who at age 45 felt a lump in her breast that didn’t show up in her regular mammograms. After additional screening, JoAnn was diagnosed with an advanced form of breast cancer and underwent eight surgeries, eight rounds of chemotherapy, and 30 rounds of radiation. Because of her experience, JoAnn cofounded DenseBreast-info.org to provide women with resources to understand breast density and advocate for themselves. We spoke to her about what we should know about breast density and our risk factors and how to start the conversation with health care providers. Our interview has been edited for length and clarity.
Short on time? Here’s what to know:
At least 4 in 10 women have dense breasts, which makes breast cancer more likely and harder to detect on a mammogram.
When you get a mammogram, you will receive a report on whether your breasts are considered dense. If they are, you may need additional screening, even if you had a clear mammogram. You should talk to your doctor about your breast density and other risk factors to determine if you need additional screening.
For women with dense breasts, additional screening options such as an MRI, contrast-enhanced mammogram, or ultrasound can identify cancers that a standard mammogram may miss. It’s important to remember that any type of screening can result in a “false alarm” (or a false positive), which is why you should talk to a doctor about risks and benefits.
Additional screening isn’t always covered by insurance, depending on your policy, state, and risk factors. You can ask your doctor to help you advocate for insurance coverage if you’re at risk. Advocates are trying to pass a federal law that would ensure at-risk women don’t have to pay for additional screening when they need it.
Mia Armstrong-López: What is dense breast tissue, and how does it affect cancer rates and screening?
JoAnn Pushkin: All breasts are made up of a combination of glandular tissue and fibrous tissue, which aid with milk production, [along with] fatty tissue. A woman that has dense breasts has a higher proportion of the glandular and the fibrous tissue.
About 40% of women have dense breasts. Dense breasts both increase the risk of developing breast cancer and [the risk] of having that cancer missed on a mammogram.
When you have your mammogram, your breast density is rated into one of four categories. The last two categories—heterogeneously dense and extremely dense—are considered dense breasts.
For those 10% of women that have extremely dense breasts—and I had extremely dense breasts—about half of cancers present will be “hidden” on a mammogram. The woman will be told her mammogram is normal, as I was, but there can be a hidden cancer. So women need to understand what breast density is and the implications for the risk of developing breast cancer and how effective a mammogram will be.
MAL: How did you first become aware of dense breast tissue?
JP: In the worst possible way. I was going for regular mammograms, never skipped one. About eight weeks after a prior mammogram, I was doing a self-exam, and I feel a lump. I really wasn’t too worried—I had just had a normal mammogram. But they always say to call your doctor, and I did that. I went in to see him, and he also felt the lump. He sends me on for a diagnostic mammogram and then for follow-up ultrasound.
So they do the exam, the tech does the second mammogram, and she come[s] back in and says, “OK, that was all clear.” It was a large facility with multiple waiting rooms, and I just assumed she’d come back into the wrong room. And I said, “Oh no, I’m the lady with the lump so big I can feel it.” And she said, “You have dense breasts, that’s going to be a very hard find for us.”
I didn’t even know what this meant. So then I go in for the ultrasound, and there it is, clear as a bell. My first thought was confusion, because it didn’t seem like a very unusual occurrence to the tech. And that was my first tip-off that, I really need to understand this, because this seems very common to her.
By size and stage, it was estimated to have been growing in my breasts three to five years—and missed on a mammogram every single one of them because it was hidden in dense tissue. Every single one of those years, I get a letter after my mammogram telling me it’s “normal.” Women with dense breasts are often shocked to learn that to be told your mammogram is normal, if you have dense breasts, does not reliably mean that cancer is not there.
MAL: Presumably, if you had been told earlier that you had dense breast tissue, and that there were other screenings that might be more appropriate for you, you would have done them.
JP: Of course. I would have said, “Oh, OK, tell me about that.” My cancer was no longer early-stage when it was diagnosed, and because no one had given me that information, I was effectively denied the opportunity for an early-stage diagnosis. I can’t advocate for myself in the absence of information.
After my diagnosis, I fought for a law in New York for women to be told the density of their breasts after a mammogram. There were many other women who were also fighting for laws in their own states. Based on all that patient advocacy and resulting individual state laws, the FDA in September 2024 issued a federal requirement that women be told in the letter that they get after their mammogram whether their breasts are “dense” or “not dense.” If a woman has dense breasts, she will be notified that it increases risk, hides cancers, and she should discuss this along with her other risk factors with her health care provider to decide what screening is appropriate.
Prior to that, individual state laws varied widely. Some didn’t even tell the woman she had dense breasts. So that was a real inequity for American women: depending on where you lived, the level of information that you had to possibly save your life varied. The big win was certainly the standardization of that notification.
MAL: In terms of what women can do, I should look at that letter I get after a mammogram, ask: Does it say my breasts are dense?, and if it says they’re dense, go back to the provider. What does that conversation with the provider look like?
JP: The tricky thing is, normally the pipeline is that you start with your referring provider, they give you the referral, then you go for the mammogram, and now you’re not going to see that provider again until next year, and that mammogram is normal.
So it involves you calling and saying, “I’ve just been told my breasts are dense, here are my other risk factors, should we talk about my family history, my personal history?” Women need to understand what their risk factors are, and then say: “Is my mammogram enough?”
MAL: If the answer is no, the mammogram is not enough, what options do women have?
JP: That’s when she really needs to sit with her doctor to decide her level of risk of both developing breast cancer and of having that cancer hidden in dense tissue. Either having heterogeneously dense or extremely dense breasts and one or two other risk factors can put a woman in a category where she qualifies as a high-risk patient. Most women don’t know that, and most health providers don’t know that. Generally recommended for women with dense breasts is another screening tool, usually a contrast method, so an MRI, a contrast-enhanced mammogram, or MBI, and if those aren’t available, an ultrasound. The addition of any of those after a mammogram will increase the cancer detection rate.
Risk factors may change from year to year; patients should discuss their risks every year with their provider. Generally, breast density doesn’t change from year to year until you begin to get older—through menopause it can begin to go down somewhat, but not always. My mother is 88 years old and has dense breasts.
MAL: When we talk about these screenings, what should insurance cover, what might it not cover, and how can people advocate for themselves around insurance coverage?
JP: Women are now being told, through federal regulation, that their breasts are dense, which increases their risk and could hide their cancer. To close that screening circle for these women, the next thing we should provide is insurance coverage with no out-of-pocket costs. Currently, insurance might cover it, but there might be a copay and deductible, and some of those can be prohibitive. Even with good insurance, an MRI copay and deductible could be $1,800. Because a mammogram alone is incomplete screening for women with dense breasts, whatever it takes to complete the screening should be covered like the mammogram, with no out-of-pocket costs.
Some individual state laws already provide for that. But there are plans that are exempt from those state laws. That’s why we need a federal law.
MAL: If I'm someone who's on an insurance plan that isn't going to cover this additional screening, can I work with my provider to get a letter of medical necessity, or are there other avenues that I can take?
JP: The first thing is to discuss with your provider and have a really good risk analysis done. You first need to understand your own risk factors, and now we're going to factor in your density. Sometimes the provider will have to discuss medical necessity with the insurance company, a woman will have to appeal—they have to really jump through hoops sometimes to get the screening they need. And that seems quite unfair.
MAL: If someone doesn’t have insurance or can't get these screenings covered, are there resources that you would point them to?
JP: Usually in each state there is a cancer society. Sometimes it's run through the state, and sometimes through an advocacy organization that might have resources and suggestions on how to get those screenings.
MAL: What are some of the key questions or prompts that you suggest to women who want to make sure they're having the right conversations with their providers?
JP: First, they need to be educated to advocate for themselves—on our website there's a fact sheet to assist. I understand that density has increased my risk, I understand that it hides cancers. If you have extremely dense breasts: I have extremely dense breasts, I see that cancer will be hidden about 40% of the time if it's there. So, what's the plan? What are the alternatives that we need to discuss? I think you need to have very pointed conversations about what you're aware of and what you need. And to ask, I'd like a risk assessment, and if you can't do it, is there a high-risk specialist that you can refer me to? You just have to really keep advocating for yourself. If they say, I don't think you need more screening, you certainly can say, Why?
Well-Informed: Related stories from the ASU Media Enterprise archives
Still have questions about breast screenings? Dr. Bhavika Patel answers common questions in this interview for Arizona Horizon on Arizona PBS.
Well-Versed: Learning resources to go deeper
Interested in learning more about dense breasts—including whether your mammogram is enough to detect potential cancer? Check out these educational videos from densebreast-info.org.
Well-Read: Articles we’ve found useful this week
“How to Protect Yourself in Extreme Cold,” by Simar Bajaj, Jan. 23, 2026, The New York Times
“Flu Activity Nationwide Declines but ER Visits for School-Aged Kids Increasing: CDC,” by Youri Benadjaoud, Richard Zhang, and Mary Kekatos, Jan. 23, 2026, ABC News
“Physician-Produced Videos on Internet Flunk Evidence Test,” by Charles Bankhead, Jan. 24, 2026, MedPage Today
Well-Defined: Word of the week
Formulary
How do I know which medications are covered by my insurance? That’s where your health insurance plan’s formulary comes in.
A formulary is a list of medications that your insurance will cover, and each insurance plan comes with its own list. If you’re prescribed a medication that’s not on your formulary, you can ask your health care provider if there’s another medication on the list that you could take instead (for example, if you were prescribed a brand medication, could you take a generic?), or you can request an exception from your insurance company.
To locate your formulary, log-in to your member portal or call the member services number on your insurance card.
-Kitana Ford, health communication assistant
Well-Engaged: Your right to your medical records
Did you know that federal law protects your right to access your electronic health records? While health care providers are required to keep your information private, you can request your records—for example, test results or most clinical notes. This information can help you make fully informed decisions in your care, and it also makes it easier to switch between and collaborate with multiple providers, further expanding your rights as a patient. If you’d like to request your records, ask your provider what process you should follow.
-Mel Moore, health communication assistant
Do you have a question or topic you’d like us to ask an expert about? We want to hear from you.
Powerful piece on dense breast awareness. The detail about how a clear mammogram doesn't reliably mean no cancer for dense tissue is something more peopel need to grasp. My cousin had a similar experience where supplemental ultrasound caught what the mammo missed - turned out to be stage 1 instead of potentiallyadvanced.