Mammogram Mayhem

I have spent a lot of time on the phone recently with several patients trying to explain a new law that went into effect in Georgia on July 1, 2019 that requires mammography providers to tell their patients about their breast density. This is a good thing!  You should know what your breast density class is and that there is other testing available that may be better for you.

There are 4 classes of breast density:

A. 10% Almost entirely fatty-----------------------------------Mammogram is a good test
B. 40% Scattered areas of fibro-glandular density----------Mammogram is a good test
C. 40% Heterogeneously dense--------Mammogram MAY NOT be the best test for you
D. 10% Extremely dense-----------------Mammogram MAY NOT be the best test for you

Please note that you can have a completely “normal” or “benign” result from your mammogram test and still have a class C or D density.

This was all in response to one woman's breast cancer being missed on a mammogram. I feel bad for her. I completely understand that our legislators do not want this to happen to anyone else, but this knee-jerk response is affecting 50% of the women in Georgia and possibly increasing costs unnecessarily. I report...you decide...if it is good or not.

HB 62 (now a law) requires mammography providers to notify patients about their breast density. It is also known as “Margie’s Law,” named after patient advocate Margie Singleton, who had breast cancer missed by a mammogram due to her dense breast tissue.  According to the legislation, the report sent to patients in Georgia should read exactly as follows if you have a Class C or Class D breast density:

**Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it more difficult to detect cancer through a mammogram. Also, dense breast tissue may increase your risk for breast cancer. This information about the result of your mammogram is given to you to increase your awareness. Use this information to talk with your health care provider about whether other supplemental tests in addition to your mammogram may be appropriate for you, based on your individual risk. A report of your results was sent to your ordering physician. If you are self-referred, a report of your results was sent to you in addition to this summary.

Dr. Pam wants you to know that there is no part of the law requiring the insurance companies to cover payment for these tests.  This is the bad thing... I’ll let you guess how many insurance companies cover it. This places Health Care Providers (HCPs) in Georgia in a very bad medico-legal position. Please understand that many other states have already passed this law.

So...what will happen if you have a “normal” mammogram or one that reports “benign findings” but you have a class C or D breast density? 

1. The radiologist has to tell the HCP if you have a Class A, B, C, or D breast density. They have to tell YOU, too and send the letter with the exact wording above.**

2. Once the HCP has this information, they have to tell you that you have a Class C or D breast density.

3. The HCP has to tell you that when you have a Class C or Class D breast density, a breast cancer can be missed.

4. The HCP should tell you that when you have a Class C or Class D breast density, mammography (even 3D-mammography or a diagnostic mammogram) may not have been the right test for you.

5. The HCP may offer you other imaging to try to assure that you do not have breast cancer because the mammogram may not have been the correct test when you have a class C or D breast density.

6. The HCP may offer you a bilateral breast ultrasound and/or a breast MRI.

7. No insurance company or Medicare pays for the breast ultrasound ($500+) or the MRI ($8000+) unless you have other risk factors (see GAIL Model and Tyler-Cuzick breast cancer assessment tools in last paragraphs), or strong family histories, or positive genetic risk.

8. The Georgia law did NOT make the insurance companies pay for the tests (some states do make them pay).

9. The fact that this is a law now makes the physician potentially liable for missing the breast cancer if they do not offer additional imaging.

10. The response from the medical liability insurers (malpractice companies that insure physicians) is that HCPs should do what is best for the patient and to protect themselves from unnecessary litigation.  You do not have to do it, but the HCPs probably will offer it.

This is a portion of the position statement from the American College of Obstetricians and Gynecologists (ACOG) in July 2019:

LEGISLATIVE INTERFERENCE WITH PATIENT CARE, MEDICAL DECISIONS, AND THE PATIENT-PHYSICIAN RELATIONSHIP

Government serves a valuable role in the protection of public health and safety and the provision of essential health services. The American College of Obstetricians and Gynecologists (ACOG) supports this proper role of government. Laws that veer from these functions and unduly interfere with patient-physician relationships are not appropriate. Absent a substantial public health justification, government should not interfere with individual patient-physician encounters.  The patient-physician relationship is essential to the provision of safe and quality medical care and should be protected from unnecessary governmental intrusion. Efforts to legislate elements of patient care and counseling can drive a wedge between a patient and her health care provider, be that a physician, certified nurse-midwife, certified midwife, nurse practitioner, or physician assistant. Laws should not interfere with the ability of physicians to determine appropriate treatment options and have open, honest, and confidential communications with their patients. Nor should laws interfere with the patient’s right to be counseled by a physician according to the best currently available medical evidence and the physician’s professional medical judgment. ACOG strongly opposes any governmental interference that threatens communication between patients and their physicians or causes a physician to compromise his or her medical judgment about what information or treatment is in the best interest of the patient.  Laws that require physicians to give, or withhold, specific information when counseling patients, or that mandate which tests, procedures, treatment alternatives or medicines physicians can perform, prescribe, or administer are ill-advised...

What should you do now?  Be informed!  Take a look at this Power Point discussion from a few years ago from the FDA: 

https://www.fda.gov/media/100208/download

Please look up the American Radiology Society and the American Cancer Society position statements on this topic:https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Reporting-Breast-Density 

https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/mammograms/breast-density-and-your-mammogram-report.html

What should you do if you currently have a Class C or D Mammogram?

First, go to one of the websites below and see what your true risk is.  These are Breast Cancer Risk Assessment Tools that help estimate the likelihood of a woman developing breast cancer in the next 10 years and over the course of her lifetime.  These tests help to inform women and help support the decision-making process for counseling, more imaging, genetic testing, and follow-up.

1. National Cancer Institute (NCI) Gail model Web site (which is accessed 20,000 to 30,000 times per month demonstrating the strong demand for this information). 

https://bcrisktool.cancer.gov/calculator.html

2. Tyrer-Cuzick model (also called the IBIS [International Breast Cancer Intervention Study] Breast Cancer Risk Evaluation Tool).  

https://ibis.ikonopedia.com

If your risk is high, or you feel that because of your family history, risk assessed by the assessment tools, or you just want a personal discussion with a physician, make an appointment with your PCP or ask to see a breast surgeon or specialist. 

I hope this helps everyone understand your mammogram report and the reason that your HCP may recommend further testing of your normal mammogram.