Breast density dilemma

For the last five years, a wave of legislation has swept through states from coast-to-coast mandating that women be notified if they have dense breast tissue that not only increases cancer risk, but also makes cancers harder to spot on mammography. But will a study questioning the cost-effectiveness of supplemental ultrasound screening reverse the tide?

Published online in Annals of Internal Medicine, the study from Brian L. Sprague, PhD, with the University of Vermont, and colleagues evaluated the value and cost-effectiveness of supplemental ultrasound screening for women with dense breasts. They used three validated simulation models incorporating lifetime horizon and federal payer perspectives, and replicated U.S. breast cancer incidence and mortality trends.

Results showed that extending supplemental ultrasound to women with either extremely dense breasts or heterogeneously dense breasts would cost $338,000 per quality-adjusted life year gained in a group of women aged 50 to 74 who received biennial screening. This number jumps to $776,000 in those screened annually starting at age 40.

Sprague and colleagues noted the findings were due to the low cancer detection rate in those who are already screened with mammography. There is also the cost of false-positives and biopsies.

Advocates for breast density notification laws challenged the results of the study.

“Computer projections using past fixed data to project the future is problematic,” said Nancy M. Cappello, PhD, founder of Are You Dense Inc. in a press release. “The future of technology changes so rapidly that this analysis lacks relevance to the now and beyond.”

Indeed, with advancing experience in the area, the performance of supplemental ultrasound may become more effective.

And it’s not as if ultrasound is the only supplemental screening modality out there. Digital breast tomosynthesis and MR are also possibilities for supplemental screening, if not as widely available currently as ultrasound.

The research into the cost-effectiveness of supplemental ultrasound is interesting, but it should not derail efforts to pass breast density notification laws—now present in 19 states, with a federal mandate waiting in the wings. Not enough people are aware of the impact that dense breast tissue has on cancer risk, and such laws—which don’t mandate actually following through with supplemental screening, only prompting discussion of risk between patient and provider—can help to bridge this education gap while more work is done to determine the best course of action for women with dense breast tissue.

-Evan Godt
Editor – Health Imaging