With Breast Density, a Gray Area for Screening Choices
The medical field, more so than many other professional arenas, is continuously struggling to balance the concepts of increasing quality metrics, decreasing overall expenditure, and riding the crest of the current technological and scientific expansion wave. Within the past half century, our profession has borne witness to an explosion of advancement, and with this has come a contemporaneous increase in both the need for sub-specialization and, bluntly, the associated cost of having more technology at our disposal.
In the healthcare community, we all share one goal: to ensure that when patients are treated, they are receiving the best and most contemporary care available. This is no easy task. Opinions can differ on what the most appropriate management of certain conditions may be. In addition, the latest innovations in medical technology may not necessarily translate into the greatest (or most affordable) advances in outcomes for our patients.
At a recent legislative meeting about the newly proposed screening methods for breast cancer, I found myself asking these very sorts of questions: Should I be a physician advocating for what I believe is the best option for patients, irrespective of the increase in my own workload and cost to society? Or should I be a representative of the non-medical world, and ask how healthcare professionals are going to handle this increase in workload and who is going to foot the bill?
Mammography is the gold standard we use for breast cancer screening and monitoring. The reasons are simple: It is fast and non-invasive, it is relatively inexpensive, and it works. Or at least it does when breast density is not a concern.
In addition to being an independent risk factor for breast cancer, dense breasts are identified radiographically in approximately 50 percent of women. The masking effect of this density is so great that even with the best digital technology and the most experienced radiologist, cancer may not be detected mammographically in up to half of these women. The frightening fact is that for the individuals who are most at risk for developing breast cancer and who require the most stringent screening, mammography alone may be futile.
Thankfully we have an armamentarium to battle this issue. The American College of Radiology (ACR) recognizes other types of imaging modalities, such as 3D digital tomosynthesis, ultrasound, molecular breast imaging, and MRI, that can detect tumors that may be missed on mammography, especially in the setting of dense breasts. (As with many newer advances, however, there is no long-term follow up yet demonstrating a significant increase in the length of survival for patients undergoing this additional screening.)
Breast density notification laws have been successfully passed in 21 states, due to the assiduous efforts of patient advocates. Many of these patient champions themselves suffered breast cancers missed on mammography due to dense breast tissue. They called upon their representatives and successfully passed these laws, which mandate imaging centers to directly notify patients of the limitations mammography has in dense breasts.
But this article would be bland if there was not some sort of debate. The American Congress of Obstetricians and Gynecologists (ACOG) — the physician population charged with the annual medical management of many women — does not recommend using additional screening tests solely because a woman has dense breasts. The organization has voiced concern over increased superfluous imaging examinations and false positives.
Indeed, breast density notification laws are inconsistent and vary between states. And unfortunately, most states do not have a concomitant insurance mandate to pay for the additional imaging. A recent study published in the Annals of Internal Medicine suggests that the addition of breast ultrasound to regular screening drives up the overall cost of imaging over the patient’s lifetime to staggering proportions, thus rendering it a substandard screening regimen.
The Breast Density and Mammography Reporting Act was introduced to the 114th US Congress this year, and sets a minimum federal standard that would necessitate mammography reports to include whether or not the patient has dense tissue. Unfortunately, this minimum standard does not necessarily propel the patient to ask the pertinent questions, nor does it provide her or the primary care provider with all the pros and cons of additional imaging. Welcome to the crossfire.
We have come a long way from the days of paternalistic medicine when patients blindly trusted their doctors. In the era of the digital universe, anybody with a smart phone has instant access to virtually every medical study published. As such, patients are more educated and more involved in their care, and rightfully so. Physicians would be remiss to consider their patients as anything other than the star player of the team. And yet with debates such as this, we find ourselves thrust back in time to the Rockwell-esque doctor who imparts his wisdom while the docile patient smiles on.
As physicians, we need proof that the tests we order are going to do some good for our patients. Since our society cannot agree on the role of additional screening, there is little momentum for insurance companies to reimburse for these studies. So while we may disagree about whether we should perform more screening, we can all agree that there’s little hope for reimbursement until we first reach our own consensus.
How can I as a radiologist tacitly endorse a “normal” mammogram when it is obviously clouded with dense breast tissue? I certainly owe more to my patients, not because they are paying me to read their films, but because their lives are at risk. Is it wrong to offer them the absolute best chance of detecting cancer early? I believe we need to shoulder this responsibility and demand more for our patients. We must offer our patients every opportunity to fight their diseases, but we must also demand that our society recognizes this increase in work and allows for the necessary compensations.
Dr. Nicole Saphier holds a seat on the Radiological Society of New Jersey’s Executive Committee and legislative subcommittee, and was recently appointed to the New Jersey Department of Health Breast Imaging Work Group. She is also on the Board of Health and Joint Municipal Alliance in her local area of Morris Township, New Jersey. Dr. Saphier is a Diplomat of the American Board of Radiology and is the recipient of a multitude of research awards, as well is the lead author of numerous peer reviewed journal publications.