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The Latest Mammogram Controversy: Density

Many Women Aren’t Told Their Breast Type May Cloud Cancer Screening; More States Consider Notification

Nancy Cappello had annual mammograms for a decade and each time radiologists noted in their reports that she had dense breast tissue. But doctors never told Ms. Cappello, nor did they warn her that it could make her mammograms less reliable.

When her doctor found a suspicious ridge during a manual exam eight years ago, she had a mammogram and an ultrasound on the same day. The mammogram again spotted nothing amiss, but an ultrasound found a tumor the size of a quarter. Her breast cancer had also spread to 13 lymph nodes.

Ms. Cappello, then 51, was dismayed to learn that the tumor wasn’t visible on a mammogram because dense breast tissue like hers can frequently hide cancer from view. “I kept asking my gynecologist, ‘Why don’t you routinely tell women this?’ And the answer I got was, ‘That’s not the standard procedure,’ ” she says.

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In 2005, while still undergoing chemotherapy, radiation and surgeries, Ms. Cappello, an education administrator in Woodbury, Conn., started a campaign called “Are You Dense?” to educate other women about dense breast tissue.

Thanks in part to her efforts, last month, New York became the fourth state, after Connecticut, Texas and Virginia, to require radiologists to inform women if they have dense breasts along with their mammogram results. Similar bills are pending in 12 states and Congress. They face opposition from insurers and major medical groups concerned that the information could raise health-care costs and scare women unduly.

Studies show that having dense breasts raises the risk of developing breast cancer fourfold to sixfold. “It’s a greater risk factor than having a mother or sister with the disease,” but few women know this, says Deborah J. Rhodes, a preventive medicine specialist at the Mayo Clinic in Rochester, Minn. “Most of the physicians ordering these tests are also in the dark about this and the implications for women,” she says.

Ultrasounds and MRIs are much more effective at spotting breast cancer. Studies show that ultrasounds find three to four additional cancers per 1,000 women with dense breasts that mammograms miss. But those tests are usually reserved for women at high risk of developing breast cancer. Using them in addition to mammograms for women with dense breast tissue could add considerably to the cost of screening.

Women’s breasts are a mixture of dense tissue and fatty tissue (which is less dense), and generally become more fatty with age. Density can’t be determined in a physical exam, only by imaging. An estimated 66% of premenopausal women, and 25% of postmenopausal women, have breasts that are dense enough to interfere with mammogram accuracy, according to a landmark 1996 study.

In studies of thousands of patients, Thomas Kolb, a New York radiologist who specializes in breast-cancer detection, showed that mammograms missed 60% of cancers in women with the densest breast tissue that were found on ultrasound. Other studies have showed similar results.

Comparing Imaging Costs

Based on the national average Medicare reimbursement:

  • Film mammogram, $81.35
  • Digital mammogram, $139.89
  • Breast Ultrasound, $99.39
  • Breast MRI (both breasts) $716.83

Source: American College of Radiology

“I, as a radiologist, have a problem telling a woman with dense breasts that her mammogram is normal when I know it could be inaccurate 60% of the time if she has cancer,” says Dr. Kolb.

Still, the American College of Radiology says there isn’t enough evidence to recommend that women with dense breasts have routine ultrasound screening.

The American College of Obstetricians and Gynecologists says it is up to radiologists, not the OB-GYNs, to determine whether mammograms are sufficient. ACOG also opposed the bill in New York state because it requires radiologists to advise women with dense breasts that they may have an increased risk of breast cancer.

“Most women of child bearing age will receive this notification and they’ll say, ‘Oh my God, what should I do now?’ ” says Donna Montalto, executive director of ACOG’s New York chapter. OB-GYNs will likely recommend that they have ultrasounds–but mainly because of the threat of malpractice suits if breast cancer is missed, she says. “That’s defensive medicine.”

Some physicians think that women with dense breasts should have regular ultrasound screenings–or at least the option to consider it. “The vast majority of women are capable of hearing this information and not freaking out,” says the Mayo Clinic’s Dr. Rhodes, who is studying a new technology, Molecular Breast Imaging, that uses a tracer substance that makes cancer cells highly visible, and which she says shows promise in detecting cancers in dense breast tissue.

Jean Weigert, an executive with the Radiological Society of Connecticut, lobbied against the notification bill there on the grounds that it would increase costs and anxiety without much benefit. But once it passed, in 2009, she was impressed with its impact. Pooling data on 78,000 women in six different practices, Dr. Weigert found that about half of the women, or 8,651 patients, with dense breast tissue went on to have ultrasounds which found 28 cancers that weren’t visible on mammograms. “We are definitely finding more cancers, most of them at very early stages,” says Dr. Weigert

Connecticut, the first state to pass a notification bill, also requires insurers to pay for ultrasounds for women with dense breasts. According to Dr. Weigert’s analysis, the additional screening for those 8,652 women cost $2.15 million, or $110,000 for each additional cancer found. Finding cancers early saves many times that amount compared with the cost of late-stage cancer treatment, she notes.

The dense-breast debate comes at a time when the value of breast-cancer screening in general is being questioned. The U.S. Preventive Services Task Force in 2009 recommended against annual mammograms for women in their 40s and said that women 50 and older should have them only every other year. (ACOG and many breast-cancer groups still recommend them annually starting at age 40.)

Last week, in an editorial in the British Medical Journal, two Dartmouth researchers accused the advocacy group Susan G. Komen for the Cure of overstating the value of early detection in its ads while not telling women that screening can result in many false alarms and treatments for cancers that might not have been life-threatening. “Everyone agrees that mammography isn’t perfect, but it’s the best widely available detection tool that we have today,” Chandini Portteus, Komen’s vice president of research, evaluation and scientific programs, said in a statement. Other experts say that breast-cancer deaths have dropped 30% in the U.S. since 1990, due at least in part to early detection from widespread screening.

Even without legislation, some experts note that women can ask about their breast density, since radiologists routinely report that information to physicians. “If women are at all concerned, after a mammogram, they can call their doctors and say, ‘Listen, do I have dense breasts? Do I need anything further?’ ” says Carol Lee, chair of the American College of Radiology’s Breast Imaging Commission.

Source: August 7, 2012, page D2 in the U.S. edition of The Wall Street Journal, with the headline: The Latest Mammogram Controversy: Density.

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