Breast cancer screening a balance of cost-effective and life-saving
Jeffrey D. Allred, Deseret News
SALT LAKE CITY — When breast cancer is detected at its earliest stage, it is at its most treatable. And the easiest way to do that in a cost-effective manner is with mammography. But a stunning number of women in the Intermountain region don't have the test that could save their lives.
"The biggest issue in my opinion in imaging is the women in our state and region do not get screening mammograms. We are last or next to last in the country in terms of women who have insurance getting them. And screening mammograms save lives," said surgeon Dr. William Rees of the Salt Lake Clinic.
Rees and Dr. Brett Parkinson, medical director of the Breast Care Center at Intermountain Medical Center, will answer questions about breast cancer screening and treatment Saturday from 10 a.m. to noon at the Deseret News/Intermountain Healthcare Hotline. The number is 1-800-925-8177. All calls are confidential.
Parkinson said specialists who diagnose, treat and sometimes see women die of breast cancer are working hard to find the disease at its earliest stage, when it shows up on a mammogram as a calcium deposit in a duct, rather than when it has become invasive carcinoma. But mammography isn't perfect and it misses as many as 10-15 percent of breast cancers, particularly in patients who have dense breast tissue.
Other tests, including screening ultrasound, that might detect such cancers are not covered as a screening tool by most insurance, although it can be used to confirm a diagnosis. And that's a challenge. A pair of major clinical trials by the American College of Radiology Imaging Network found that ultrasound picked up more cancers than mammography alone. But the results were not reproducible because it hinges on the thoroughness and expertise of the person holding the ultrasound device. And automated systems for screening breast ultrasound have not been thoroughly vetted, though two manufacturers have won regulatory approval.
Magnetic resonance imaging (MRI) also picks up cases that might not have been detected as early with mammography. It's probably "the most powerful screening tool we have," Parkinson said. But it's expensive. And like a screening ultrasound, it comes with what is, thus far, an unacceptably high rate of false positives. There are questions about the cost-benefit ratio.
It's also hard to prove how many lives are saved by some of the screening modalities, because screening clinical trials traditionally have not had death as the end point, he noted. Still, "conservative estimates" put it at 30 percent.
Screening all women with MRIs would assuredly find more cancers, "but it would be so prohibitively expensive, it doesn't make sense from a public health policy standpoint," said Parkinson. That's one of the challenges when dollars spent have to make sense.
Such tests, though, are likely a different cost-benefit story in patients with the highest pretest possibility of breast cancer, such as women who have had breast cancer in one breast or those who have a close relative with the disease.
Such women might benefit from consulting a geneticist to determine whether their risk qualifies them for a breast MRI as a high-risk candidate under insurer rules, he said.
Intermountain offers comprehensive breast care that includes specialists who discuss each diagnosed case of breast cancer as a team.
Tomorrow: Treatments less invasive, more selective
Dr. Brett Parkinson, medical director of the Breast Care Center at Intermountain Medical Center, and surgeon Dr. William Rees will answer questions about breast cancer screening and treatment Saturday from 10 a.m. to noon at the Deseret News/Intermountain Healthcare Hotline. The number is 1-800-925-8177. All calls are confidential. You can also post questions on Facebook at https://www.facebook.com/desnews during hotline hours and the experts will answer them.
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