Screening Mammography: Caught in the Crossfire
In November 2009, the U.S. Preventive Services Task Force (USPSTF) shocked the breast imaging community with its controversial screening mammography recommendations, which included shifting the annual screening routine to a biannual exam for women between the ages of 50 to 74 and eliminating screening entirely for women younger than age 50 and older than age 74.

One year later, Centers for Medicare and Medicaid Services (CMS) reports have shown that 20 percent of American women between the ages of 50 to 74 are behind on mammography screening, and more than half of U.S. women between 40 and 49 years of age are not undergoing regular mammograms, the American Cancer Society says. The data suggest a reversal of the trend toward steady increases in screening mammography since the 1990s. While the decline cannot be attributed entirely to the USPSTF recommendations, 17 states slashed funding for breast cancer screening programs in 2010 and many Americans have lost jobs as well as insurance coverage over the last year.

The recommendations spurred anger and confusion among all breast imaging stakeholders: radiologists, referring physicians, payors and women. “It’s unfortunate that the group of individuals on the task force, none of whom had any experience with breast cancer or screening—no radiologists, breast surgeons or medical oncologists—who had materials presented to them by biased individuals, would then come out and endanger women this way,” asserts Dan Kopans, MD, professor of radiology at Harvard Medical School and senior radiologist in breast imaging at Massachusetts General Hospital in Boston.

In the wake of the recommendations, insurers and state funders have altered policies and eligibility criteria, referring physicians have changed screening advice for their patients, breast imagers have seen screening volume drop and women are bypassing mammograms. This month, Health Imaging & IT explores the short-term ramifications of the recommendations.

Insurers and state funding

After the guidelines were released, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius predicted minimal impact. “Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.” Maybe not. Five states cited the recommendations when they cut funding for screening programs.

California’s Every Woman Counts, a cancer detection program targeting underserved women, will not admit any new patients due to budget shortfalls. In Ohio, funding for the state’s mammography program was slashed from $2.5 million in 2008 to 2009 to $700,000 this year.

Practice impacts

While hard data quantifying the specific role that the recommendations have played in the screening downturn may not be available yet, Debra Monticciolo, MD, vice president of the Society of Breast Imaging (SBI) believes that some insurance providers are cutting back or denying breast screening coverage for certain age groups. “There is a general impression of a decline among breast imagers,” she says, adding that some physicians have reported a nearly 20 percent decline in volume.

The once-full Temple Clinic of the Scott and White Healthcare System in Temple, Texas, exemplifies the state of the market. In the past, the clinic had to expand hours to meet demand; now, regular openings for mammography appointments are available.  

Other factors also take a toll on screening rates. According to a March poll question from the Radiology Business Management Association (RBMA):
  • 44 percent of practices reported decreases between 0 to 20 percent in mammography volume;
  • 9 percent reported decreases of 21 to 40 percent; and
  • 2 percent reported decreases between 31 to 40 percent.
Although 93 percent of respondents attributed the decline to a poor economy or unemployment, nearly 71 percent also believed that the USPSTF recommendations shouldered the blame for at least part of the decrease.   

Referring physicians on the fence

“Some of our referring doctors are telling their patients they don’t need a mammogram until their 50s, and we are having women who may have had a baseline in their 40s call after they receive a recall card to tell us their doctor said they don’t need another until age 50,” explains Stamatia Destounis, MD, of the Elizabeth Wende Breast Care Center in Rochester, N.Y.  

Breast imagers express a two-pronged concern. Women are postponing or foregoing annual mammograms, and referring physicians are relying on the recommendations to advise patients. According to a poll published in the Annals of Internal Medicine soon after the USPSTF recommendations were issued, 67 percent of physicians reported that they would follow the task force’s guidelines in their screening recommendations for their patients.  

Kopans believes referring physicians’ willingness to adhere to the guidelines can be attributed to an incomplete understanding of the data behind the recommendations.

Patients slipping through the cracks

The biggest fear for breast imaging professionals? They might see the breast cancer mortality rate rise over the next decade as a result of women in their 40s not being screened, states Kopans.

After the task force guidelines became public, some women in their 40s presenting with lumps were refusing mammograms, noted Destounis. “We are trying explain the importance of mammography and educate patients regarding their fear of radiation risk,” she says, noting that this has to be done for both patients and their physicians.  

The recommendations have confused some women, believes Monticciolo, noting that levels of mammography utilization fell this year. “I don’t think we have gotten back to the level of acceptance we had previously—at least not yet,” she offers.

HHS to the rescue

In July, HHS issued new guidelines suggesting private health plans cover annual or biannual mammography screening beginning at age 40 and older for women.

But while Destounis says the HHS guidelines have the potential to improve funding and access, Monticciolo believes it will be hard to reverse women’s beliefs. The HHS guidelines face a public relations hurdle as unlike the USPSTF recommendations, the HHS guidelines did not generate the same amount of headlines or public backlash.

Kopans worries that the damage may already be done, and Destounis speculates, “Are patients going to remember there is a reduction in mortality with yearly screening and that the prognosis is good, even if a small cancer is detected through screening? Or, are they going to remember the statement from the task force?”   

Confusion continues

As federal and state agencies, payors and breast imagers attempt to establish clinical and economic clarity, clinical research continues to muddy the waters. While a Swedish study reported that screening mammography cut breast cancer mortality by nearly 30 percent among women aged 40 to 49, Norwegian researchers more recently attributed modest mortality reductions of approximately 3 percent to screening mammography. It appears that mammography will not leave the crossfire any time soon.