While Obamacare is the ultimate political Frisbee, a different set of laws—about breast cancer screening —may soon have physicians’ heads spinning.

To date, five states1 have enacted some form of legal requirement that the significant percentage2 of women with dense breasts be apprised of the limitations of radiographic mammography and informed of alternate or adjunct imaging options. Now, in addition to having to help patients navigate conflicting studies about the when of screening, providers also have to guide patients through the how. Even in states (including Massachusetts) where such laws are not in place, physicians should be prepared to address this emerging aspect of breast care with an eye toward patient safety.

Radiologists and primary care physicians (PCPs) are trying to determine what to write and what to say to patients that is both legally compliant and reflective of appropriate care. The biggest challenge is the lack of clinical evidence that screening alternatives for women with dense breasts, i.e., whole breast ultrasound and MRI, are beneficial. Providers have to convey to patients both sides of the potential consequences of additional screening without increasing their own risk of being deemed liable for a missed or delayed breast cancer diagnosis.

Given that patients—especially women who have a screening mammogram—have increased access to their medical records and reports, radiologists and PCPs will do well to coordinate their breast density messaging. Wording the information about density in the mammogram report to help the PCP frame the patient discussion (about screening options) will reduce tension between providers. Along with the foundation of evidence-based care, clearly documenting what was discussed, and the patient’s expressed plan (if any) for subsequent imaging will be a strong defense for PCPs whose standard of care is later questioned.

While the breast density issue has received considerable attention, malpractice cases related to breast cancer more frequently involve the mismanagement of symptomatic patients than insufficient screening.3 Capturing and updating patient and family histories, and following breast complaints to resolution will best position physicians to provide optimal care that can be defended against allegations of diagnostic missteps. To that end, CRICO’s Breast Care Management Algorithm offers PCPs a clear course of best practices that balance evidence-based care with practical risk management recommendations.

Additional Materials


  1. California, Connecticut, New York, Virginia, Texas
  2. The relationship of mammographic density and age: implications for breast cancer screening
  3. Process of Care Failures in Breast Cancer Diagnosis

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