Mammograms may miss tumors in women with dense breast tissue. So for these patients, doctors often order a second scan — such as an ultrasound or MRI — that is more likely to catch the cancer in its early stages.
But some older patients are experiencing an unexpected turn. Although many women view additional scans as a routine preventive measure, health insurance won’t cover the cost, and some patients have to shoulder hefty bills.
Joellen Sommer, 66, who lives in Manhattan, had her annual breast cancer screening in March. But clinic staff said that while her mammogram would be fully covered by Medicare, the so-called supplemental ultrasound was not.
Ms. Sommer has dense breasts and a family history of breast cancer. She said she has had mammograms and ultrasound imaging throughout her adult life. “I just don’t understand why a diagnostic test that has been recommended for years is suddenly not covered by health insurance,” she said.
“My mother had breast cancer, my aunt had breast cancer – I guess that’s not enough,” she added. “I wonder if this is a test for men and if the same issues arise.”
Lenox Hill Radiology in New York City has begun warning patients that if they have Medicare insurance they could face reimbursements of up to $450 if they undergo a breast ultrasound, even if the breast tissue is known to be dense And the additional scan is done on the same day as the screening mammogram.
An information sheet provided to doctors notes that Medicare does cover breast ultrasounds in limited circumstances, such as “evaluation of palpable or nonpalpable breast masses, hazy mammograms, and other signs or symptoms suggestive of breast cancer.”
Guidelines on when and how often to screen for breast cancer have changed over the years, but mammograms, which use low-dose X-rays to detect lesions, have long been the gold standard for early detection.
But a mammogram can’t actually “see” tumors in dense breast tissue; both appear white in X-rays. Dense breasts are not uncommon: Although density declines with age, nearly half of women age 40 and older who have mammograms have dense breast tissue, according to the National Cancer Institute.
Breast tissue is considered dense when it has more fibrous and glandular tissue and less fatty tissue.
Starting in September, all mammography centers in the United States will be required to tell patients undergoing breast cancer screening if they have dense breasts. Despite regular mammograms, women are discovering their cancers at advanced stages, leading to efforts to draw attention to the shortcomings of mammograms in these patients.
Dense breast tissue itself is a risk factor for breast cancer. Women with extremely dense breasts have twice the risk The study found that compared with those who had what’s called “dispersed dense tissue,” or dense tissue throughout the breast.
Advocates say a mammogram alone is an “incomplete screening” for women with dense breast tissue, and some scientists agree. Dr. Dorraya El-Ashry, chief scientific officer of the Breast Cancer Research Foundation, said supplemental ultrasound is currently the standard of care for secondary screening of dense breasts.
“For women with the densest breasts, mammograms miss about half of the cancers,” said JoAnn Pushkin, executive director of the educational group DenseBreast-info.
Ms Pushkin said the most common questions the group received were from women trying to get supplemental tests or find out why they were not covered by insurance.
She added: “Many cancers are left on the treatment table and opportunities are missed to detect them at their earliest stages, when they are most treatable and survivable.”
The group is supporting the Find It Early Act introduced by Rep. Rosa DeLauro, D-Conn., and Rep. Brian Fitzpatrick, R-Pennsylvania. The measure would ensure that all health insurance plans cover screening and diagnostic breast imaging, including mammograms, ultrasounds and MRIs, without cost-sharing.
A spokesman for the Centers for Medicare and Medicaid Services said its policy has not changed: Medicare provides 100 percent of annual radiation screenings for women 40 and older as part of preventive care.
But an agency spokesperson said in an email that the agency distinguishes between mammograms and other screening tests such as ultrasounds and promotes them as diagnostic tools.
There is also no general consensus on the value of alternative screening for women with dense breasts. The American College of Radiology says 3D mammograms increase the number of cancers found without additional testing, while ultrasound and MRI scans can help find cancers that can’t be seen with mammograms.
But neither the American College of Obstetricians and Gynecologists nor the U.S. Preventive Services Task Force endorse additional breast cancer screening for patients with dense breast tissue. The organization said clinical trial data were insufficient to do this.
Supplementary screening methods also have disadvantages, such as a higher rate of false positives with ultrasound, which can lead to unnecessary anxiety and follow-up care, and higher costs associated with MRI scans.
But in A letter to the working group last year, Ms. DeLauro and Rep. Debbie Wasserman Schultz, D-Fla., said several of the panel’s recommendations put women’s lives at risk, including that the task force failed to “recognize support for dense breasts.” Substantial evidence for additional screening of patients.”
