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.
