USA TODAY International Edition
3D mammograms getting the hard sell
Aggressive marketing has many women feeling pressured into high- tech breast cancer screenings, even though there’s no evidence they save more lives, an investigation shows
When Dr. Worta McCaskill- Stevens made an appointment for a mammogram last year, she expected a simple breast cancer screening – not a heavyhanded sales pitch.
A receptionist asked if she wanted a free upgrade to a “3D mammogram,” or tomosynthesis.
“She said there’s a new approach and it’s much better, and it finds all cancer,” said McCaskill- Stevens, who declined the offer.
A short time later, a tech asked: Was the patient sure she didn’t want 3D?
Upselling customers on high- tech breast cancer screenings is just one
way the 3D mammography industry aggressively promotes its product.
A Kaiser Health News investigation found manufacturers, hospitals, doctors and some patient advocates have put their marketing muscle – and millions of dollars – behind 3D mammograms. The juggernaut has left many women feeling pressured to undergo screenings, which, according to the U. S. Preventive Services Task Force, haven’t been shown to be more effective than traditional mammograms.
“There’s a lot of money to be made,” said Dr. Steven Woloshin, director of the Center for Medicine and Media at the Dartmouth Institute for Health Policy and Clinical Practice, who published a study in January showing that the health care industry spends $ 30 billion a year on marketing.
Enthusiasm for 3D has sparked a medical technology arms race as hospitals and radiology practices compete to offer the newest equipment. When rural hospitals can’t afford 3D machines, foundations often pitch in to raise money. More than 63% of mammography facilities offer 3D screenings, first approved for sale in 2011.
Taxpayers write the check for many 3D screenings, which add about $ 50 to the cost of a typical mammogram. Medicare, which began paying for 3D exams in 2015, spent an additional $ 230 million on breast cancer screenings within the first three years of coverage. By 2017, nearly half the mammograms paid for by Medicare were 3D, according to a KHN analysis of federal data.
Peter Valenti of Hologic, a 3D equipment manufacturer, said the company’s marketing is educational. Hologic is a “for- profit organization, but our premise is to try to improve the health care for women globally,” said Valenti, president of the company’s breast and skeletal health solutions division.
The debate over 3D mammograms illustrates the tension in the medical community over how much research companies should do before commercializing products. In a statement, Hologic said it would be “irresponsible and unethical” to withhold technology that detects more breast cancers, given that definitive clinical trials can take years.
The ‘ false alarm’ factor
On average, 3D screenings may slightly increase cancer detection rates, finding about one extra breast tumor for every 1,000 U. S. women screened, according to a 2018 analysis in the Journal of the National Cancer Institute. Most studies also show that 3D screenings cause fewer “false alarms,” in which women are called back for procedures they don’t need, said Dr. Susan Harvey, a Hologic vice president.
Yet newer tech isn’t necessarily better – and it can cause harm, said Dr. Otis Brawley, a John Hopkins University professor. “It’s unethical to push a product before you know it helps people.”
As a senior researcher at the National
Cancer Institute, McCaskill- Stevens didn’t need a glossy brochure to learn about 3D mammograms. She helped design a $ 100 million federally funded study that will measure whether women are helped or hurt by 3D testing. The study, now recruiting patients, will follow the women for five years.
“Can we say that 3D is better?” asked McCaskill- Stevens. “We don’t know.”
The American Cancer Society, Susan G. Komen and the U. S. Preventive Services Task Force also say there isn’t yet enough evidence to advise women on 3D mammograms.
When the Food and Drug Administration approved the first 3D mammography system, made by Hologic, the agency required the technology to be safe and effective at finding breast cancer – not at improving survival.
Describing a breast exam as 3D may conjure up images of holograms or virtual reality. In fact, tomosynthesis is closer to a mini- CT scan.
Although all mammograms use Xrays, conventional 2D screenings provide two views of each breast, one from top to bottom and one from the side. 3D screenings take pictures from multiple angles, producing dozens or hundreds of images, and take only seconds longer.
Yet some studies suggest 3D mammograms are less accurate than 2D.
A 2016 study in The Lancet Oncology found that women screened with 3D mammograms had more false alarms. A randomized trial of 29,000 women published in The Lancet in June showed 3D detected no more breast tumors than 2D mammograms did.
Diagnosing more cancers doesn’t necessarily help women, Brawley said. That’s because not all breast tumors are life- threatening; some grow so slowly that women would live just as long if they ignored them – or never knew they were there. Finding these tumors often leads women to undergo treatments they don’t need.
A 2017 study estimated 1 in 3 women with breast cancer detected by a mammogram are treated unnecessarily. It’s possible 3D mammograms make that problem worse by finding even more small, slow- growing breast tumors than 2D, said Dr. Alex Krist, vice chairman of the U. S. Preventive Services Task Force, an expert panel that issues health advice. By steering women toward 3D mammograms before all the evidence is in, “we could potentially hurt women,” Krist said.
Some experts worry patients are choosing treatment out of fear.
“If there was ever an audience susceptible to direct- to- consumer advertising, it’s women afraid of breast cancer,” Zuckerman said.
Changing the law
For years, women who wanted a 3D screening had to pay an extra $ 50 to $ 100 out- of- pocket.
Valenti said Hologic wanted more women to have access, so it launched a public campaign to pressure private insurers to cover 3D.
Hospitals and radiology practices, which stand to benefit from an expanded pool of paying customers, are also fierce advocates for insurance coverage.
In 2017, a doctor at New York’s Memorial Sloan Kettering Cancer Center asked a local assemblywoman to introduce a bill requiring insurance coverage for 3D screenings. In a statement, an official at Memorial Sloan Kettering said the hospital supported the bill to improve patient care.
Supporters of 3D mammograms also rallied around an insurance mandate in Texas in 2017. Registered supporters included HCA Healthcare, a for- profit chain that manages 185 hospitals, and the Black Women’s Health Imperative.
Linda Goler Blount, president and CEO of the Black Women’s Health Imperative, said the group was advocating for early detection long before its partnership with Hologic began in 2016.
The American Society of Breast Surgeons lists Hologic as a corporate partner. In May, the society recommended 3D mammograms as its preferred screening method.
“There is no connection between the society’s educational grants and statement development,” said Sharon Grutman, a society spokeswoman.
Fran Visco, president of the National Breast Cancer Coalition, said she’s at a loss for a solution to curtail industry influence in medicine.
“It’s incredibly troubling,” said Visco, a breast cancer survivor. “Everyone has a different stake in all this, and it all seems to be tied to financial gain.”