Additional breast cancer screening is not right for all women, experts say

When Katie Couric shared the news of her breast cancer diagnosis, the former host of NBC’s “Today” show said she saw this new health challenge as a teachable moment to encourage people to get needed cancer screenings.

“Please get your annual mammogram,” she wrote on her website in September. “But just as important, find out if you need extra screening.”

In the essay, Couric, 65, explained that because she tends to have dense breast tissue, in addition to mammograms, she is also given an ultrasound test when screening for breast cancer. A breast ultrasound, sometimes called a sonogram, uses sound waves to take pictures of breast tissue. It can sometimes identify malignancies that are difficult to detect on a mammogram in women with dense breasts, which have a high ratio of fibrous tissue to glandular to fatty tissue.

Couric, who underwent a colonoscopy on live television after her first husband died of colon cancer and lost her sister to pancreatic cancer, has long pushed for better cancer screening and detection.

Breast cancer experts applauded Couric for bringing attention to breast density as a cancer risk factor. But some were less pleased with the defense of the additional screening.

“We don’t have any evidence that supplementation reduces breast cancer mortality or improves quality of life,” said Dr. Carol Mangione, a professor of medicine and public health at UCLA who leads the US Preventive Services Task Force, a group of medical experts. who make recommendations for preventive services after weighing the benefits and harms.

Couric’s office did not respond to requests for comment.

In addition to annual mammograms, some women with dense breasts have a breast ultrasound or MRI to help identify cancer cells missed on mammograms. Dense fibrous tissue appears white on a mammogram and makes it difficult to see cancers, which also appear white. Fatty breast tissue, which appears dark on mammograms, does not hide breast malignancies.

As digital breast tomosynthesis, or 3D mammography, becomes more widely available, increasing numbers of women are undergoing this screening test rather than the standard 2D mammogram. 3D mammography has been shown to reduce the number of false-positive results and identify more cancers in some women with dense breasts, although the effect on mortality is unknown.

The task force gives an “I” grade to additional screening for women with dense breasts whose mammogram results do not indicate a problem. This means that the current evidence is “insufficient” to assess whether the benefits of extra screening outweigh the harms. (The task force is currently updating its recommendation on breast cancer screening, including additional screening for women with dense breasts.)

An important disadvantage that researchers are concerned about, in addition to the possible additional cost, is the possibility of a false-positive result. In women at low risk for breast cancer, additional imaging can identify problem areas, which can lead to follow-up tests such as invasive breast biopsies and raise the fear of cancer in many patients. But research has found that these results are often false alarms.

If 1,000 women with dense breasts have an ultrasound after a negative mammogram, the ultrasound will identify two to three cancers, research shows. But additional imaging will identify up to 117 potential problems, prompting recall visits and tests, but ultimately determined to be false positives.

“On the one hand, we want to do everything we can to improve detection,” said Dr. Sharon Mass, an obstetrician-gynecologist in Morristown, New Jersey, and past president of the American College of Obstetricians and Gynecologists’ New Jersey chapter. . “But on the other hand, there’s a lot of cost and emotional distress” associated with false positive results.

The professional group does not recommend additional screening for women with dense breasts who do not have additional risk factors for cancer.

Many other professional groups take a similar position.

“We recommend having a conversation with a health care provider and helping patients understand whether their breasts are dense,” Masse said. “But we don’t recommend everyone get tested.”

In particular, for about 8 percent of women with very dense breasts, it’s worth having a conversation with a doctor about additional testing, Masse said.

Also, for women with dense breasts who have additional risk factors for breast cancer, such as a family history of the disease or a personal history of breast biopsies to check for suspected cancers, additional screening may make sense, she said.

Dense breasts are quite common. In the United States, 43% of women over 40 have breasts that are considered dense or very dense. Research shows that not only are mammograms more difficult to interpret, but women with dense breasts are twice as likely to develop breast cancer than women with average density breasts.

Studies have shown that mammograms reduce breast cancer mortality. But while it may seem intuitive that more testing would improve someone’s chances of beating cancer, studies have not found that women are less likely to die from breast cancer if they have an additional ultrasound or MRI after a negative mammogram result.

Some studies have found that women with dense or very dense breasts who had an ultrasound or MRI in addition to a mammogram had fewer so-called intermediate cancers between screening mammograms. But it is not clear whether these results affect the risk of dying from breast cancer.

“Not every small abnormality will lead to something that needs treatment,” Mangion said.

Thirty-eight states and the District of Columbia have laws requiring patients to be notified of breast density after a mammogram, although some require a general notification rather than requiring women to report their condition. Some states require insurance to cover additional tests, but others do not.

In 2019, the FDA proposed that breast density information be included in the letters patients receive after a mammogram. That rule hasn’t been finalized yet, but the agency has told lawmakers it expects to issue the rule by early next year at the latest.

In a statement to KHN, FDA spokeswoman Carly Kempler said, “The FDA is committed to improving mammography services for patients and is working diligently to finalize the rule to amend existing mammography regulations.”

The cost of additional tests is another factor to consider. Because the Preventive Services Task Force recommends that women get regular screening mammograms, health plans generally must cover them at no out-of-pocket cost to people. Not so with additional screening for women with dense breasts, which the task force does not recommend. Some states require insurance coverage for these tests, but those laws do not apply to many plans where employers “self-fund” employee benefits instead of purchasing state-regulated insurance coverage.

Additional imaging can be expensive if not covered by your health plan. A screening ultrasound can cost $250 out of pocket and a breast MRI can cost $1,084, according to the Brem Foundation for Young Breast Cancer.

Rep. Rosa DeLauro (D-Conn.) tweeted recently working on an invoice With Couric, it would cover MRIs and ultrasounds for women with dense breasts at no out-of-pocket cost.

Some doctors recommend other steps that may be more effective than additional screening for women with dense breasts who want to reduce their risk of breast cancer.

“If you really want to help yourself, lose weight,” said Dr. Karla Kerlikowske, a professor of medicine and epidemiology/biostatistics at the University of California, who has worked with other researchers to develop calculators to help providers evaluate patients. risk of breast cancer. “Moderate your alcohol consumption and avoid long-term hormone replacement. Those are things you can control.”