The USA is a country where individuals, if they are sufficiently determined, can make a major impact on society. One such person is Nancy Cappello whom we featured in a blog a few years ago. A routine mammogram in late 2003 was reported as normal and yet six weeks later ultrasound revealed a 2.5 cm tumour that was diagnosed as stage IIIC breast cancer. How could this happen? How did a mammogram – the gold standard – lead to a false negative diagnosis?

Cappello was told that her dense breast tissue had masked the cancer, making it invisible to X-rays (see four examples at right). This experience galvanised her to persuade the legislators in her home state of Connecticut to introduce a law that not only obliged radiologists to inform patients about their breast density, but also required insurance companies to pay for whole-breast ultrasound as an adjunct to mammography. Cappello launched a website called AreYouDense.org and became an advocate for breast density notification laws all over the country. There are now 28 states that have enacted legislation and a team of radiologists from California has just published a paper in The Breast Journal that reports on the impact of the new breast density laws.

Lina Nayak (seen below left) and her colleagues put together a 20-question survey that was sent to radiologists in the Society of Breast Imaging, with 110 facilities from 34 states responding. The researchers gathered information in five areas: demographic data; breast cancer risk assessment; estimating breast density; types of supplemental screening; and education for referring doctors.

Half the facilities were in states that had introduced legislation and yet there was no significant difference in performing risk assessments between facilities in states with a law and those without. One third of the facilities had introduced adjunctive screening modalities, including hand-held ultrasound (HHUS), automated breast ultrasound (ABUS), and digital breast tomosynthesis (DBT), while 40% had started to perform risk assessments using models such as Tyrer-Cuzick and Gail. These percentages were not higher apparently because key questions remain unresolved: Which imaging modality is most effective? Which patients would benefit from supplemental screening? Which modalities are covered by insurance?

Nayak told AuntMinnie.com, “Women are now increasingly aware of the possibility that screening mammography may not be enough to detect cancer, particularly if they are at high risk.” An important question, not answered by this study, must be asked: Has the introduction of the legislation led to an increase in the early detection of breast cancer? Time will tell.