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Mammogram muddle

Conflicting guidance on cancer screenings


A recent report released in the New England Journal of Medicine is reigniting the debate of when women should get mammograms – and who is most likely to benefit from them.

The latest study by the International Agency for Research on Cancer concluded that there is “a net benefit” for women age 50 to 69 from mammogram screenings to reduce the risk of dying from breast cancer. However, for women in their 40s, the agency found a “limited benefit.”

The group also found that routine mammography screenings can result in overdiagnosis of breast cancer.

The researchers from 16 countries weighed the benefits of screening using various methods, including mammography, breast self-examination, ultrasound and magnetic resonance imaging against the incidence of cancer.

This guidance rekindles questions over when and how often to use mammograms for cancer screenings. In 2009, the U.S. Preventive Task Force changed its recommendations on mammograms. Under the old guidance, women should have mammograms every one or two years starting at age 40. The updated recommendations said women should start regular mammogram screenings at age 50 and have the test every other year.

The task force stated: “There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years.”

The panel did say that women in their 40s should discuss the benefits and risks of mammography with their doctors in order to make an informed decision about the screenings.

According to the task force, a patient and doctor would need to weigh the level of anxiety that could be caused by false positive test results and unnecessary imaging tests and biopsies in women without cancer, among other considerations.

Nonetheless, the American Cancer Society and the American College of Obstetricians and Gynecologists still urge routine yearly screening for women beginning at age 40. The cancer society states “recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s.”  

The differing guidelines issued by each group cause confusion for doctors as well as patients, said Dr. Lance Lassiter, an oncologist at Novant Health Cancer Specialists in Matthews, North Carolina.

“It’s hard to come up with a definitive recommendation when well-respected bodies have differing guidance,” Lassiter said. “Most physicians support the American Cancer Society recommendations of annual mammograms beginning at age 40.”

Doctors will also take family history and genetic predisposition into account in determining when a patient should have a screening.

According to the National Cancer Institute, breast cancer risk factors include:

  • A woman’s age at the onset of her period.
  • Age at first live birth.
  • “First-degree relative” such as mothers, sisters or daughters diagnosed with breast cancer.
  • Number of previous breast biopsies, including both negative and positive results.

The National Institutes of Health has an online quiz to help assess knowledge of breast cancer risk factors.

One consequence of the new guidelines is that women could lose access to free mammograms from their insurers, according to an analysis by Avalere Health, a health care consulting firm.  

The author of the Avalere study told National Public Radio that in a worst-case scenario 17 million women could have claims rejected if every single insurer refused to cover mammograms for women aged 40 to 49. Though that situation appears unlikely, there is a chance that some insurers might reject claims for these preventive screenings or ask that women in that age range bear some of the cost of the tests.

“If that does occur, it would likely dissuade some patients from getting a mammogram and lead to patient harm,” Lassiter said.

Craig Pergrem, senior director for patient access at Novant Health’s revenue cycle services, said that if a doctor had reason to suspect that a patient needed a mammogram, insurance would likely cover the cost the test, but that such a situation would require additional authorization on the part of the hospital and the physician to get the patient scheduled.

“If a patient had no coverage and wanted the screening test, it would be considered a self-pay and it would be an out-of-pocket expense to the patient ranging between $100 to $225, depending on the location and type of mammography,” he added.





Published: 6/17/2015