Whenever I write about the topic of breast cancer, it conjures up many memories.
My mother had breast cancer in an era when surgery involved removal of chest wall muscles as well as the breast. I saw the disfigurement. As a teenager, I went shopping with her to a medical supply business where she tried on post-mastectomy bras in a supply closet.
This was pre-mammography times, when the first sign of trouble was a lump felt in the breast. A radiological technologist, my mother never ignored such signs. Still, breast cancer struck the second time, though by then analog mammography was available. Later she developed a brain tumor.
I'm so grateful today we have ever-improving technology that detects the tiniest of tumors. Fort Wayne's Breast Diagnostic Center recently purchased three-dimensional imaging equipment that research shows gives a 20 percent to 40 percent improved cancer detection rate over two-dimensional digital mammography, which has been the standard modality for more than a decade.
The system, called tomosynthesis, takes 15 quick X-ray images of breast tissue at multiple angles as the imaging machine moves in an arc over the breast. A computer converts the images into 60-120 “slices” to produce the 3-D mammogram.
The machine also takes a 2-D digital mammogram, which normally involves just two pictures of each breast, explained Dr. William Petty, medical director of Breast Diagnostic Center, a joint venture of Fort Wayne Radiology and Parkview Health.
Women still undergo the same breast compression, and the length of compression is a few seconds longer when adding 3-D to the 2-D time, but Marita Dwight-Smith, director of Breast Diagnostic Center and a mammography technician, says compression varies woman to woman based on breast tissue density and size of breasts.
Reducing false positive callbacks
Women with dense breasts and women who have had breast surgery are at greater risk for missed tumors as well as for false positives. Tissue can overlap and appear as a tumor or calcification.
Because of tomography's ability to provide pictures of suspicious areas from multiple angles, “It is great for women with dense breasts or larger breasts,” Petty said.
That leads to another plus for the technology: It reduces callbacks by up to 30 percent for women in which a mammogram reading shows a suspect area but later proves to be a false-positive.
“About 10 percent of women get called back,” Petty said, noting callbacks can lead to more tests such as ultrasound and MRI, greater costs and high anxiety in women until they are told all is OK.
Breast Diagnostic Center is currently the only site in the Fort Wayne area offering 3-D mammography. The technology was approved by the FDA in 2011, but insurers are not yet, or are rarely, covering it.
That was the story with MRI breast screening for years. However, in Indiana in 2013, a new law went into effect that mandates women be informed if they have dense breasts and that insurers cover additional screenings such as MRI for such women. MRI is the most expensive of screening modalities, Petty said, but is it also the most sensitive in detecting tumors.
It remains to be seen whether interpretation of the law could mean Indiana insurers will soon begin covering 3-D mammography for such women. A national billing code for tomosynthesis has been established and is anticipated to go into effect early next year.
Still, a position statement, published in January on the Web by Anthem Blue Cross Blue Shield maintains: “Digital breast tomosynthesis is considered investigational and not medically necessary for all indications.”
Lutheran Health Network is moving ahead with plans to purchase tomosynthesis mammography.
“Physicians and leadership from Lutheran Health Network are evaluating how 3-D mammography may best be used for patients with dense breast tissue,” said spokeswoman Lizette Downey. “We anticipate offering it in the near future for that identified population.”
Concerns have been raised about the increased radiation exposure that adding 3-D brings. Petty points out the radiation exposure with the combined 3-D and 2-D screening is twice that of 2-D alone, but the overall exposure is only about one-third what Hoosiers get on any given day with normal activities.
More data needed for insurers
IU Health based in Indianapolis has had 3-D mammography for three years, said Dr. Hal Kipfer, section chief of breast imaging for Indiana Radiology Partners. He also is assistant professor of clinical radiology for IU School of Medicine-Indianapolis.
“In a perfect world, I think we'd do 3-D on everyone,” Kipfer said. “It's going to detect cancers regardless of your risk ahead of time.” But the biggest gain “is the benefit of having fewer false positives.”
When one red flag appears with 2-D, looking at the area with 3-D adds specificity to screenings. Reducing false positives could also mean reduced radiation exposure because of fewer additional diagnostic tests.
In this era of stringent health-care cost containment, Kipfer says 3-D mammography machines, which cost upwards of $400,000, will likely replace 2D at a much slower pace than 2-D replaced analog machines after their 2000 FDA approval.
Though he has radiologist friends in other states who are getting some reimbursement for 3-D, clinical trials on the modality have been limited.
“Until we have a good multi-center trial, it's going to be hard to get insurance approval,” Kipfer said.
In the meantime, Dwight-Smith said that if 3-D is desired by a woman or recommended by the radiologist, the additional out-of-pocket fee is $50. A standard mammogram, which in Indiana is covered by all insurers, costs $285 at the center.
I have two daughters, a daughter-in-law and six granddaughters.
With new diagnostic technology and breast cancer treatment advances, I am very hopeful for their futures, and mine. But when age-appropriate, we women all must take that step to have regular mammograms, whether they are 2-D, 3-D or both.
If my mom were alive today, she'd be first in line.