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Connecticut has been doing screening US for all women with C and D density with no other risk factors since 2009, and finding 3-4 cancers per thousand women screened, essentially doubling the cancer detection rate over mammo alone.
The vast majority are small, invasive (not DCIS) and node negative, with PPV low at first but improving over time. That would be my first choice. If forced to ration, perhaps screening US for all category Ds and for category C with another risk factor, like + family history, but
you risk missing cancers in the Cs. Any woman considering US screening (or any screening for that matter) should be aware of the likelihood of false alarms, especially the first time she has the test. We find complicated cysts, fibroadenomas, etc.
Sometimes this leads to a recommendation for short interval follow-up, and sometimes a needle biopsy (depending on how sure we are that it isn't cancer). Better safe than sorry.
That's why screening US should ideally be done at a place that will do the necessary follow-up, and needle biopsy when the occasion arises. ACR recommends MRI for women with dense breasts who've had cancer.
