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Objective:
Breast density (BD) notification legislation, aimed at informing patients about their breast density and associated risks, has been implemented in 38 states. However, it has been shown that BD literacy is still limited. The disparities in awareness have been associated with ethnicity, education level, and socioeconomic status. Understanding the drivers of these disparities is crucial to ensure equitable patient education. This is especially pertinent since the FDA has issued a national requirement for BD reporting, effective September 10, 2024. This study investigates how ethnicity, education level, and physician access have an impact on health literacy about BD and understanding of the California Breast Density Notification Law.

Materials and Methods:
There were 273 women with a median age of 50–59 enrolled from three breast centers in Los Angeles. Eligibility criteria included age > 30, not pregnant or lactating, and heterogeneously or extremely dense breasts. This IRB-approved 30-question multiple choice survey gathered demographics, health history, healthcare access, and BD awareness and knowledge level. Participants were classified as having low or high health literacy. Poisson regression models were used to analyze risk factors associated with low health literacy.

Results:
We found that 47.1% of Hispanic (H) women (32/76) were unaware that they had dense breasts, compared to 16.2% of Non-Hispanic (NH) women (32/197). Among patients with a regular physician, 79.3% (165/208) showed awareness, and those without had an awareness rate of 63.6% (14/22). Awareness was 56.3% (18/32) for high school-educated, and 82.9% (180/217) for college-educated or higher. Among those aware, 48.5% (16/33) of H women and 61.5% (75/122) of NH women could correctly describe BD. Learning about BD through notification letters led to explanatory proficiency in 33.3% of H and 56.6% of NH women. In comparison, learning about their BD through a conversation with a physician resulted in explanatory proficiency in 60.0% of H and 65.6% of NH women. Through notification letters, 50.0% of H and 79.2% of NH women reported being aware of BD’s obscuring effect of cancer detection on mammography. Through conversations with physicians, the rates rose to 80.0% and 86.9%, respectively.

Conclusion:
Our study reveals apparent disparities in BD awareness and knowledge among ethnic groups in the greater Los Angeles area. This gap is most pronounced in H women, who are less aware of their BD and its potential consequences than NH women. This gap persists even when they read their BD notification letters. Discrepancy diminishes when patients discuss BD with a physician. These findings underscore the need to improve existing notification strategies to ensure that all patient populations, particularly those with varying ethnic and educational backgrounds, receive comprehensive information about BD and its implications for their health.