In an effort to detect hidden breast cancers, Virginia is poised to become the third state to require radiologists to notify women if they have dense breast tissue.
This month, the General Assembly without opposition passed legislation requiring radiologists to put information about breast density in the federally mandated post-mammogram letters already sent to patients.
Gov. Bob McDonnell will sign it, a spokeswoman said, calling it a "common-sense measure to ensure women's health."
Dense breast tissue makes it harder to detect cancer with a mammogram. But there is debate over whether women with dense tissue are at increased risk for breast cancer. Some medical experts caution that the wave of breast density laws being proposed throughout the country may be premature and harmful, and could result in unnecessary - and expensive - tests.
The concern: What women will do with the knowledge that they have dense breasts.
"What we don't know is whether telling them that information gives them anything to act upon," said Dr. Barbara Monsees, chairwoman of the American College of Radiology Breast Imaging Commission. "Does it change what they can do or what they should do?"
Current scientific research doesn't answer those questions.
Monsees said the laws could undermine the confidence that women have in mammography if they are told the test may not detect cancer.
"That would be a shame because we know mammography saves lives," she said.
For those who have fought for the legislation in Virginia and elsewhere, the reasoning is simple: Women have the right to be informed about their health.
"I came at it from the perspective as well, trying to get patients to be their own best advocate," said Del. Bobby Orrock, R-Caroline County, who sponsored the bill in the House.
Connecticut and Texas have passed similar laws, and 13 other states are considering legislation. A federal bill was introduced in the House last year.
Roanoke resident Joan Vannorsdall, 60, first learned she had dense breast tissue in August when she was diagnosed with breast cancer. After requesting a decade's worth of mammogram results from her medical file, Vannorsdall learned that radiologists had been noting her dense breast tissue as far back as 2003.
"That was really the stunner to me," she said. "It made me think, maybe mammography wasn't the magic silver bullet."
After all, every mammogram she had, including the one in August, came back negative.
Vannorsdall's cancer was detected not by the annual screening, but by her gynecologist, who thought she felt something during a physical exam. It wasn't until an ultrasound was done that anything suspicious was found.
A biopsy later revealed the cancer.
Vannorsdall began to research breast density and soon came across a Connecticut-based advocacy group, Are You Dense, which has led a campaign to educate women about breast density. The group is engaged in the legislative efforts throughout the country and played a role in the Virginia bill.
Vannorsdall testified before the Senate Education and Health Committee in January.
"It is a matter of life and death to women," she said. "And this will save lives."
Not everyone agrees.
"The real question is, 'Will we save lives? Will we improve the treatment?' " said Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society. "We don't have an answer. There has been no systematic study that has been done."
About half of women who have a mammogram have some degree of breast density, according to the American Cancer Society.
"I certainly agree that women need to understand both the benefits, risks and limitations of screening mammograms," Lichtenfeld said. "That is important. Quite honestly... we have not done a very good job of doing that."
The society hasn't taken a position on breast density legislation, he said.
The Virginia legislation does two things. First, it requires a radiologist to report breast density to the physician who ordered the mammogram. Second, if that report indicates that a woman does have dense breast tissue, then the patient must be informed in her post-mammogram letter.
As approved by the General Assembly, that letter will read: "Your mammogram demonstrates that you may have dense breast tissue, which can hide cancer or other abnormalities. A report of your mammography results, which contains information about your breast density, has been sent to your referring physician's office, and you should contact your physician if you have any questions or concerns about this report."
The medical community supports the requirement that radiologists report breast density to physicians, and Monsees said that has been part of the American College of Radiology's recommendations for years.
It is the wording of the letter to patients that caused a behind-the-scenes debate about the Virginia legislation. The Medical Society of Virginia and the Virginia chapter of the American College of Radiology argued against the original wording, which would have suggested that additional screening tests might be warranted.
"If you indicate to a patient that there are other diagnostic tests that are better, it is misleading," said Ann Hughes, the lead lobbyist for the Medical Society of Virginia.
Other imaging tests, such as MRIs and ultrasounds, are used to detect some breast tumors in women at high risk for breast cancer, but they are imperfect, medical experts say. They are expensive and generally not covered by insurance for routine screening.
The concern is that if more women start having screening ultrasounds or MRIs, more biopsies of suspected tumors might be performed. But more biopsies also might come back negative, and the additional testing may not result in fewer deaths.
Vannorsdall said any opportunity to detect breast cancer and save a life should justify the tests. While she said she is disappointed that the wording of the letter was "watered down," she is happy the legislation will prompt the discussion between a woman and her doctor.
It's that conversation that the two men who sponsored Virginia's legislation said they wanted to encourage.
"Hopefully, it will save lives and provide women with the education they need about their particular situation," said Sen. John Edwards, D-Roanoke.
By Sarah Bruyn Jones