Journal of General Internal Medicine

, Volume 34, Issue 8, pp 1441–1451 | Cite as

The Impact of Breast Density Notification Laws on Supplemental Breast Imaging and Breast Biopsy

  • Loren Saulsberry
  • Lydia E. Pace
  • Nancy L. KeatingEmail author
Original Research



Dense breast tissue increases breast cancer risk and lowers mammography sensitivity, but the value of supplemental imaging for dense breasts remains uncertain. Since 2009, 37 states and Washington DC have passed legislation requiring patient notification about breast density.


Examine the effects of state breast density notification laws on use of supplemental breast imaging and breast biopsies.


Difference-in-differences analysis of supplemental imaging and biopsies before and after notification laws in 12 states enacting breast density notification laws from 2009 to 2014 and 12 matched control states. Supplemental imaging/biopsy within 6 months following an index mammogram were evaluated during four time periods related to legislation: (1) 6 months before, (2) 0–6 months after, (3) 6–12 months after, and (4) 12–18 months after.


Women ages 40–64 years receiving an initial mammogram in a state that passed a breast density notification law or a control state.


Mandatory breast density notification following an index mammogram.

Main Measures

Use of breast biopsies and supplemental breast imaging (breast ultrasound, tomosynthesis, magnetic resonance imaging, scintimammography, and thermography), overall and by specific test.

Key Results

Supplemental breast imaging and biopsy increased modestly in states with notification laws and changed minimally in control states. Adjusted rates of supplemental imaging and biopsy within 6 months of mammography before legislation were 8.5% and 3.1%, respectively. Compared with pre-legislation in intervention and control states, legislation was associated with adjusted difference-in-differences estimates of + 1.3% (p < 0.0001) and + 0.4% (p < 0.0001) for supplemental imaging and biopsies, respectively, in the 6–12 months after the law and difference-in-differences estimates of + 3.3% (p < 0.0001) and + 0.8% (p < 0.0001) for supplemental imaging and biopsies, respectively, 12–18 months after the law.


As breast density notification laws are considered, policymakers and clinicians should expect increases in breast imaging/biopsies. Additional research is needed on these laws’ effects on cost and patient outcomes.


breast cancer cancer screening health communication health policy health services research 



We acknowledge and sincerely thank Dr. Kenneth L. Kehl for his guidance and consultation on methodology for determining an incidence cohort for breast cancer from the Truven Marketscan claims databases.


Dr. Saulsberry’s effort was supported by R25 CA92203 from the National Cancer Institute. Dr. Pace’s effort was supported by an American Cancer Society Cancer Control Career Development Award for Primary Care Physicians and 1K07CA215819-01A1 from the National Cancer Institute. Dr. Keating’s effort was supported by K24CA181510 from the National Cancer Institute.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Loren Saulsberry
    • 1
  • Lydia E. Pace
    • 2
    • 4
  • Nancy L. Keating
    • 3
    • 4
    Email author
  1. 1.Department of Public Health Sciences, The University of ChicagoChicagoUSA
  2. 2.Division of Women’s HealthBrigham and Women’s HospitalBostonUSA
  3. 3.Department of Health Care Policy Harvard Medical SchoolBostonUSA
  4. 4.Division of General Internal MedicineBrigham and Women’s HospitalBostonUSA

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