Dense Breast Notification Laws: Impact on Downstream Imaging After Screening Mammography

Abstract

Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Many states have recently enacted dense breast notification (DBN) laws to provide patients with information to help them make better-informed decisions about their health. To test whether DBN legislation affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI), we examined the proportion of times screening mammography was followed by ultrasound or MRI for a series of months pre- and post-legislation. The subjects were women aged 40 to 64 years, covered by private health insurance, undergoing screening mammography from 2007 to 2014. Except for Hawaii, Maryland, and New York, DBN legislation significantly increased the probability of ultrasound follow-up in all states that implemented DBN legislation before December 2014. It also increased the probability of MRI follow-up in California, North Carolina, Pennsylvania, and Texas. The financial and access consequences merit further study.

Performance of Screening Ultrasonography as an Adjunct to Screening Mammography in Women Across the Spectrum of Breast Cancer Risk

“…5,6 In addition, notification requirements may include statements that women are at higher breast cancer risk because of their breast density, that breast density may adversely limit the ability of mammography to detect breast cancers, and that women with mammographically dense breasts may want to consider supplemental screening. 1,[7][8][9] Data from the Breast Cancer Surveillance Consortium (BCSC) indicate that 43% of women undergoing screening mammography aged 40 to 74 years have dense breasts, including 57% of women aged 40 to 44 years. 10 Studies of screening ultrasonography have included women with additional risk factors beyond breast density who were at intermediate to high breast cancer risk either due to a personal history of breast cancer or high-risk benign breast lesions or because of genetic susceptibility.…”

“You probably can’t feel as safe as normal women”: Hispanic women’s reactions to breast density notification

“…This is consistent with the current breast cancer screening guidelines that only recommend supplemental screening to mammography for women who are at an elevated risk of breast cancer, and do not include specific recommendations based on breast density alone. Nonetheless, in a growing number of states with BDN legislation, health insurance policies now incorporate breast density as a criterion for providing benefits for breast ultrasound screening, and a recent analysis of health care data before and after BDN legislation suggests an increase in breast ultrasound and magnetic resonance imaging within a short period of time after screening mammography . Changes in healthcare organizational practices to provide additional screening in women with dense breasts are still being investigated and are likely to have strong influences on women’s participation in supplemental screening.…”

“…Nonetheless, in a growing number of states with BDN legislation, health insurance policies now incorporate breast density as a criterion for providing benefits for breast ultrasound screening, 21 and a recent analysis of health care data before and after BDN legislation suggests an increase in breast ultrasound and magnetic resonance imaging within a short period of time after screening mammography. 22 Changes in healthcare organizational practices to provide additional screening in women with dense breasts are still being investigated and are likely to have strong influences on women's participation in supplemental screening. A study found that women screened at an academic facility serving patients of higher socioeconomic status and those screened at a county hospital serving patients of lower socioeconomic status were similarly strongly interested in receiving supplemental ultrasound for screening dense breasts (94% and 74%, Cancer June 15, 2019 respectively), but the willingness to pay out of pocket was substantially higher in patients at the academic facility compared with patients at the county facility (70% and 22%, respectively).…”

A Qualitative Study of Spanish-Speakers’ Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital

“…Data on the direct impact of breast density notification on health service use and population health is needed. 45 As a single-site study of Spanish-speaking women, women's experiences were influenced by the implementation of the legislation within this health system and established clinical processes. Perceptions and behaviors may be different across characteristics that we were unable to differentiate between, including Hispanic cultures, levels of acculturation beyond language, prior experience with mammography and abnormal results, language supports that may have facilitated care, or among other languages or care settings.…”