Breast can­cer screen­ing shifts to more sen­si­tive, costly tests

Modern Healthcare - - NEWS - By Jaimy Lee

The decades-old stan­dard of mam­mog­ra­phy screen­ing for breast can­cer is chang­ing.

De­ci­sions about screen­ing are be­com­ing more tai­lored to in­di­vid­ual pa­tients as clin­i­cians bet­ter un­der­stand risk fac­tors such as breast den­sity and fam­ily his­tory, pa­tients be­come more in­formed about per­sonal risk and imag­ing man­u­fac­tur­ers de­velop new tech­nolo­gies. About 40% of U.S. women older than 40 have dense breasts.

The screen­ing arse­nal still cen­ters on mam­mog­ra­phy but also in­cludes MRI, hand­held and au­to­mated ul­tra­sound and dig­i­tal breast to­mosyn­the­sis, a form of mam­mog­ra­phy that takes three-di­men­sional images. Screen­ing now is “ab­so­lutely more per­son­al­ized,” said Dr. Rachel Brem, di­rec­tor of George Wash­ing­ton Univer­sity’s Breast Imag­ing and In­ter­ven­tional Cen­ter.

But in­sur­ers have been slow to cover sup­ple­men­tal screen­ing meth­ods, which can cost $150 for an ul­tra­sound to $1,000 for an MRI. Pa­tients usu­ally have to pay out-of-pocket. Also, some sup­ple­men­tal meth­ods raise ques­tions about higher ex­po­sure to ra­di­a­tion, in­va­sive­ness and higher rates of false-pos­i­tive test re­sults com­pared to mam­mog­ra­phy.

To­mosyn­the­sis is one of the new­est of the ad­junct modal­i­ties. Ho­logic, a Bed­ford, Mass.-based man­u­fac­turer, in­tro­duced it to the U.S. in 2011. GE Health­care, based in Wauwatosa, Wis., re­ceived ap­proval from the Food and Drug Ad­min­is­tra­tion for its ma­chine this year.

A study re­leased at the Ra­di­o­log­i­cal So­ci­ety of North Amer­ica’s an­nual meet­ing in Chicago found that us­ing a com­bi­na­tion of dig­i­tal mam­mog­ra­phy and to­mosyn­the­sis caught 80% of can­cers in women with dense breasts, com­pared with the 59% of can­cers di­ag­nosed in those women who only un­der­went mam­mog­ra­phy. The study, fi­nan­cially sup­ported by Ho­logic, com­pared can­cer de­tec­tion rates for about 25,000 women ages 50 to 69.

About 11% of the screen­ing sys­tems in the 8,700 cen­ters cer­ti­fied by the FDA to per­form mam­mo­grams are 3-D sys­tems, most of them Ho­logic ma­chines. Women usu­ally first un­dergo a 2-D mam­mo­gram, which can be used to as­sess their breast den­sity. The ECRI In­sti­tute said the av­er­age price of dig­i­tal mam­mog­ra­phy sys­tems went up 13% over the past year be­cause more hos­pi­tals are buy­ing 3-D sys­tems. The av­er­age price of a to­mosyn­the­sis sys­tem is $417,000.

“Does this in­crease costs over­all for women? Yes,” said Dr. De­bra Mon­tic­ci­olo, sec­tion chief of breast imag­ing at Bay­lor Scott & White Health. “But in the long run, if we can find can­cers when they are smaller and lower stage, it can be a win.”

The Amer­i­can Col­lege of Ra­di­ol­ogy is­sued a state­ment last month call­ing for in­sur­ers to cover 3-D mam­mog­ra­phy.

Medi­care will cover to­mosyn­the­sis for the first time in 2015. The CMS also is in­creas­ing its pay­ment next year for ul­tra­sound screen­ing. Still, some re­searchers cau­tion against wide­spread use of sup­ple­men­tal screen­ing. A study pub­lished in De­cem­ber in the An­nals of In­ter­nal Medicine found that us­ing ul­tra­sonog­ra­phy screen­ing for women with dense breast tis­sue in­creases costs and led to false pos­i­tives with few ben­e­fits. The au­thors called for more re­search into sup­ple­men­tal meth­ods.

To­mosyn­the­sis is one of the new­est ad­junct modal­i­ties used in screen­ing for breast can­cer.

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