Summary: Breast cancer deaths are significantly reduced through early detection with screening mammography. Unlike most other areas of radiology, and medicine, breast cancer screening is heavily legislated.
Ellen Shaw de Paredes, MD, is the founder and director of
The Ellen Shaw de Paredes Institute for Women’s Imaging, Glen Allen, VA.
She is also a member of the Applied Radiology Editorial Advisory Board.
cancer deaths are significantly reduced through early detection with
screening mammography. Unlike most other areas of radiology, and
medicine, breast cancer screening is heavily legislated. The Mammography
Quality Standards Act of 1996 and its subsequent revisions in 1998 and
2004 established minimum standards for mammography facilities, and this
act requires accreditation, certification, and annual inspection of each
Four states—Connecticut, Virginia, New York, and
Texas—now have legislation mandating disclosure of breast density
directly to the patient by the facility. Numerous other states and the
federal government are considering similar legislation. In Virginia, the
law states that the following statement be placed on the letter of
results sent to a patient whose breasts are heterogeneously or extremely
dense: “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.”
I believe that patients should be informed and
educated about health-related issues. Breast density is now considered
an independent risk factor for the development of breast cancer. Breast
density also has been known to be a cause of missed breast cancers
because of obscuration of a mass by the radiopaque glandular tissue.
Many women whose breasts are dense are not aware of that fact, nor are
they aware of the associated risks of increased density.
How do we
screen those women with dense breasts for breast cancer? Additional
screening with breast magnetic resonance imaging (MRI) is recommended by
the American Cancer Society for women who are at high risk, whether
their breasts are dense or not, and as many as 14.7 additional cancers
per 1000 women per year are found in this way. Screening ultrasound is
also a tool that may be used for women with dense tissue and can detect 4
additional cancers per 1000 women per year over screening mammography
alone. However, no formal recommendation exists yet for or against
screening ultrasound in women with dense breasts. Along with the benefit
of detection of additional mammographically occult cancers, comes the
risk of a high number of false positives on screening ultrasound.
problem with the current legislative mandate in Virginia, and I suspect
in other states, is that we are not well prepared for the consequences
of the information given to the patients. Referring physicians may not
be prepared to discuss breast density with their patients. Mammography
facilities may not be prepared for performing screening ultrasounds
based on available equipment, technologists, and radiologists. We have
no CPT code for screening breast ultrasound. The code for breast
ultrasound (76645), which has been used until recently for a targeted
exam, is not really appropriate for a full screening of both breasts
with ultrasound. The skill and time for performance and interpretation
of a bilateral screening ultrasound is significantly greater than that
of a targeted study and should be coded differently and reimbursed at a
higher level. Most insurance companies do not yet recognize a screening
breast ultrasound, and therefore the patient may be left to pay out of
pocket for this study.
In Connecticut, legislation mandating
coverage for screening breast ultrasound preceded the mandate regarding
informing patients about breast density. This seems to be a far more
logical order of events than the reverse, which is what we now face
Clinical trials to show the effect on breast cancer
mortality by ultrasound screening of women with dense breasts would be
ideal, but may not be feasible given the urgency of the situation. As
clinicians, we need to act upon the information from ACRIN and other
studies to help to inform our patients about the potential role of
additional screening. We also need to be prepared to discuss the
downside of screening ultrasound, which is additional false positive
results. In our practice, we recommend screening MRI and mammography for
women at high risk, screening ultrasound and mammography for women with
dense breasts and intermediate risk, and screening mammography only for
women at low risk with or without dense breasts. This seems logical,
yet should we be prepared to offer screening ultrasound to all women
with dense breasts? Since > 40% of our patients are in the dense
breasts category, this measure does not seem feasible.
question remains, who should be offered screening ultrasound? If the
answer is “any woman with dense breasts,” we need to rapidly expand our
expertise in this area with additional technologists certified in breast
ultrasound and radiologists prepared to interpret these studies.
Perhaps with the new automated breast ultrasound (ABUS) units available,
we may have a more consistent method of performing screening
ultrasounds and following nonsuspicious findings.
Hopefully, as this issue spreads nationwide, we will be able to track some of the key questions, such as:
- To whom should we offer
- What is the benefit of additional screening in women with dense breasts?
- How do we code screening
- Do third party carriers recognize the complexity of this procedure?
Until then we are attempting to deal with the deluge of questions
from patients and clinicians about these perplexing issues, and we are
trying our best to make appropriate screening recommendations based on
risk and density.