Dense Breasts? Understanding The New Options for Breast Cancer Screening

There is no one-size-fits-all screening exam for breast cancer. Women who have a higher-than-average risk of breast cancer because of family history, genetic factors, or dense breasts may benefit from additional breast imaging beyond an annual screening mammogram.  

“While mammograms remain the gold standard for breast cancer screening, the reality is that screening with mammography alone is not optimal for women at higher-than-average risk, and some women are underserved with just mammography” says Katja Pinker-Domenig, MD, PhD, professor of radiology and chief of the Division of Breast Imaging at Columbia University Irving Medical Center (CUIMC). 

Pinker-Domenig and her colleagues are working to give women more options for breast cancer screening at Columbia, while also studying how to better predict which women may need additional screening and which tests are most appropriate for them. 

What Are Dense Breasts? 

Breasts are made up of fatty and fibroglandular tissue. When there is more fibroglandular tissue than fatty tissue, the breasts are considered dense. Dense breasts are common and are associated with a slightly higher risk of breast cancer. Dense breast tissue can also make it harder for radiologists to see cancer on a mammogram. Both dense breast tissue and many breast cancers appear white on a mammogram, which can make some cancers harder to spot. 

For this reason, many women with dense breasts are advised to have additional screening, such as ultrasound, in addition to a mammogram. Studies have found that ultrasound can detect about two to four additional cancers per 1,000 women screened compared with mammography alone. 

But ultrasound is not the only option: additional screening technologies may offer a better way to look for breast cancer in women who need more intensive screening. 

Contrast-Enhanced Mammography 

In 2026, Columbia’s Department of Radiology launched one of the first contrast-enhanced mammography (CEM) screening programs in the New York City area. 

CEM combines a standard mammogram with an intravenous contrast agent. The contrast is given through a vein shortly before the exam. Because tumors often develop an increased network of blood vessels as they grow, the contrast makes some breast cancers more visible on the resulting images. 

Women with dense tissue found on mammography, as well as women at higher-than-average risk because of factors such as family history or genetics, may be eligible for CEM at Columbia.

“The advantage of contrast-enhanced mammography is that it replaces your regular annual mammogram while giving us additional information about areas of increased blood flow that traditionally we could only see with breast MRI,” says Janice Sung, MD, professor of radiology and associate chief of breast imaging at CUIMC. CEM also provides this additional information as part of a single exam, rather than requiring two separate imaging appointments for a mammogram and breast MRI. 

Sung has researched the use of CEM for breast cancer screening for more than a decade and has found that CEM can detect approximately12 additional cancers per 1000 women screened compared withstandard mammography alone. This makes CEM nearly as sensitive as breast MRI while offering an alternative that may be more accessible and less expensive. 

“CEM finds more cancers,” explains Sung, “but also finds them earlier, when they are easier to treat.”  

Abbreviated MRI 

A breast MRI (magnetic resonance imaging) is currently the most sensitive imaging test for detecting breast cancer, but cost, access, and the length of the exam limit the number of women who can benefit from the test. Right now, for example, only those very high-risk or those who have already had breast cancer, can receive breast MRI. 

“MRI was originally conceived as a long, expensive test,” explains Pinker-Domenig, who is a world-renowned expert on breast MRI.  “One of the things we’re working on is making breast MRI more accessible to women who are at higher-than-average risk for breast cancer or who have very dense breasts.”  

This desire to make MRI available to a wider group has led to the development of an abbreviated MRI. “Abbreviated MRI is just what it sounds like—a much shorter MRI of the breast that can be completed in less than ten minutes,” says Pinker-Domenig. 

Abbreviated MRI uses a smaller number of imaging sequences than a standard breast MRI, focusing on the images most important for detecting breast cancer. The shorter protocol means less time in the MRI scanner, and fewer images for radiologists to interpret—allowing radiology centers to offer more MRI exams to patients.  

Research has found that abbreviated MRI can detect breast cancers at rates comparable to standard breast MRI. 

A recent study led by Pinker-Domenig and her team examined abbreviated MRI for monitoring women receiving chemotherapy for breast cancer, another use of breast MRI. The study found no significant difference between the abbreviated and full MRI protocols. 

“These shorter protocols can allow many more women to benefit from the most sensitive test for breast cancer detection, and that’s what makes this approach so exciting,” says Pinker-Domenig.

Beyond Breast Density: Using AI to Predict Risk 

Having more sensitive screening options can be helpful, but also raises an important question for providers: How do we know which women would benefit from additional screening? 

Despina Kontos, PhD, director of Columbia’s Center for Innovation in Imaging Biomarkers and Integrated Diagnostics (CIMBID), is working to answer that question. 

Kontos is a principal investigator on a multi-institutional grant funded by the National Institutes of Health that aims to improve the ability to identify women at elevated risk for invasive and advanced breast cancer. At the core of her work is the potential for artificial intelligence (AI) to extract information from mammograms that may not be visible to the human eye. 

Her team is studying features embedded in standard mammograms that may help identify women at higher risk. These features go beyond breast density alone. Researchers increasingly recognize that patterns and textures within breast tissue may provide additional information about a woman's future risk of developing breast cancer, even among women with similar breast density. 

The goal is not necessarily to screen everyone more often. Some women may benefit from more intensive screening, while others may be able to be screened less often. “For some women, mammograms every other year may be enough,” says Kontos, who is also a member of the Herbert Irving Comprehensive Cancer Center (HICCC) Cancer Population Science (CPS) research program.

Kontos and her team have developed AI tools that are being tested in research settings. These tools combine risk factors with measurable features from screening mammograms to help determine which women may benefit from different levels of screening. 

“We need this technology to help find those women who actually need more intensive preventative strategies and screening and deliver that care to them effectively and fully," she says.

Kontos is collaborating with Julia McGuinness, MD, a breast oncologist at Columbia to help bring these concepts into clinical practice and make risk-based screening more personalized. “What we need is a more comprehensive, risk-based approach that helps determine which patients are most likely to benefit from additional screening as well as interventions to potentially reduce their risk of breast cancer," says McGuinness.

As breast cancer screening evolves, the goal among radiologists and clinicians is not simply to offer more tests. It’s to help each woman receive the screening that is more appropriate, and accessible, to her individual risk. 

Columbia’s high-risk breast screening program brings together breast imaging, surgery, medical oncology, genetic counseling, and other specialists to develop personalized screening plans based on factors such as family history, genetic risk, breast density, and other individual factors. 

For women who have been told they have dense breasts or are at higher risk of breast cancer, having more options can mean more ways to find the screening approach that is right for them.