Should we practice what we profess? Care near the end of life.

595 variably refer patients with dense breasts for whole-breast ultrasound screening, with some practices referring 100% of such women and others referring none. Furthermore, only 45% of Connecticut women who were referred for follow-up ultrasonography actually received it.5 Still, breast-density legislation provides an opportunity to strengthen patient–provider relationships by encouraging physicians to engage women in a conversation about the risks and benefits of screening, regardless of breast density. In this era of cost containment, and given the limited data supporting screening ultrasonography, a rational and cost-effective approach to screening is needed. So how should the medical community address the growing concern over breast density and breast-cancer detection? It is critical that radiologists work with other specialists and primary care physicians to develop evidence-based recommendations regarding situations in which supplemental screening is advisable and which method is most efficacious. For example, some practices now use digital breast tomosynthesis, which leads to increased cancer detection while limiting the need for additional imaging in women with dense breast tissue, according to preliminary data. Having dense breast tissue does increase a woman’s lifetime risk of breast cancer, but it’s important for providers to place this risk in perspective for each patient. Risk stratification will be an essential tool in determining the best screening plan for each woman. It would be helpful if the medical community could reach a consensus on how best to advise women with dense breasts with regard to the limitations of various screening tests and the role of any supplemental screening. Then, practitioners could base patient care on existing evidence and each woman’s individual risk. Such an approach might well maximize cancer detection and minimize the downsides of screening — especially false positives and the risks of overdiagnosis and overtreatment. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.