Breast cancer is the second leading cause of cancer death in women. Estimates indicate a nearly 40% breast cancer mortality reduction when screening women annually starting at age 40. Although mammography is well known to be a powerful screening tool in the detection of early breast cancer, it is imperfect, particularly for women with dense breasts. In women with dense breast tissue, the sensitivity of mammography is reduced. Additionally, women with dense breasts have an increased risk of developing breast cancer while mammography has a lower sensitivity. Screening ultrasound, both handheld and automated, is effective in detecting mammographically occult cancer in women with dense tissue. Studies have shown that ultrasound significantly increases detection of clinically important, small, largely invasive, node-negative cancers. The purpose of this review article is to summarize the literature to date regarding screening breast ultrasound, emphasizing differences in cancer detection in high risk and intermediate risk women, and to discuss practical ways to implement screening ultrasound in clinical practice, including automated whole breast ultrasound, as a viable solution to the increasing need for additional screening.

Thank you for your thoughtful comments regarding breast density legislation. We welcome the opportunity for deeper engagement on this important topic. There is great variation in the language used in individual state laws informing women of breast density and we regret that this important discussion was beyond the scope of our manuscript. As discussed in the comment, some states only inform women of the concept of dense breast tissue and do not inform the woman of her individual breast density. This can cause confusion for a woman receiving the letter about her own personal status and what her next steps should be. There is a need for more universal language disclosing the woman's personal density as well as the benefit of additional screening. Many radiologists are familiar with the calls from worried patients who have just received their letter in the mail regarding breast density. This is an opportunity to provide patient-centered, value-added care. Our expertise as radiologists provide us with an opportunity to inform, educate and advise the patient on the issue of breast density. Radiologists are the best equipped to discuss the potential benefits (such as increased cancer detection) and potential disadvantages (such as false positives) that are inherent to adjunct screening modalities, such as MRI and Ultrasound. As the legislative landscape continues to evolve, radiologists should strive to engage with their patients in order to lead the way forward in patient-centered care. Conflicts of Interest: The author declares no conflict of interest.

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Objectives To describe the sonographic findings of endometrial intraepithelial neoplasia (EIN), a precursor of endometrial cancer. Methods Cases were found by word search of pathology database 1/2013 to 6/2019. One hundred and seventy‐eight patients with ultrasound <1 year prior to biopsy were included. Medical records were searched for patient data. Two radiologists blindly classified images. Differences of opinion were decided by clinical report. Univariate and multivariate analyses were performed. Results Median time between ultrasound and first sampling procedure was 49 days. Median age was 55 (range 28–85) years. Endometrial thickness ranged from 2 to 90 mm. Mean endometrial thickness was 13 ± 6 mm in the noncancer group and 16 ± 11 mm in the cancer group (P = .02). The endometrium was almost always heterogeneous 175/178 (98%). Cysts were almost always multiple (89/109, 82%) and >1 mm (72/109, 66%). Masses were most often >5 mm (56/105, 55%) and ill‐defined (41/105, 39%). Vascularity was present in 93/178 examinations (52%) and always associated with cysts and/or mass. There were 92 cancers, 25 with invasion (including 4 with tumor extension into adenomyosis). In 47 cases, the endometrial‐myometrial interface was graded as ill‐defined, 39 of whom had hysterectomy. There was macroscopic cancer in 11, microscopic cancer in 4, and invasive carcinoma in 12 patients (P for invasive cancer versus other outcomes = .02). Depth of invasion was 5‐ >95%, with 6 cancers >50%. Multivariate analysis showed thickness, polyps, and type of bleeding as the best set of independent variables for cancer (area under the receiver operating characteristic (ROC) curve [AUC] = .75). Replacing type of bleeding with age or menopausal status had AUC of .73 and .74, respectively. Conclusions EIN has a variety of sonographic appearances with thickened endometrium with cysts and masses being common. Ill‐definition of the endometrial‐myometrial interface is a poor prognostic finding when seen in the absence of adenomyosis.