A Funny Thing Happened on the Way to the Mammogram

2-D image left, 3-D right From http://www.columbia-stmarys.org/3DMammo
2-D image left, 3-D right
From http://www.columbia-stmarys.org/3DMammo

Like a lot of women my age (58) I try to get a yearly mammogram. I don’t necessarily see or speak with my women’s health care provider (in my case, a gynecologist) before I schedule the mammogram; I know she wants me to have it done, and the imaging center sends a reminder directly to me.

So this year when I called to make an appointment with the imaging center, I was surprised to be asked if I wanted 3-D mammography. I asked what it was, and I think I got an answer like “A  higher resolution breast scan done in addition to the traditional mammogram;” I asked if my insurance covered it, and they said some do and some don’t.

I guess to proceed from here I must own up to a few things: generally good health and no more than a reasonable fear of breast cancer; confidence that if a procedure were rigorously and scientifically proven valid, most if not all insurance companies would cover it; usually a household “heads-up” in important new cancer-detecting methods (my husband is a pathologist).

So I said, “No thanks.”

When I arrived for the mammogram, the woman at the reception desk asked again: Will you be having the 3-D mammogram? Nope. Went to the waiting area and the woman who called me in for the test asked the same. Nope, I said again. “Oh, you didn’t know it was offered,” was the response.

“No,” I said, “I knew about it and I refused it.” By now I’m getting a little ticked, maybe at myself, too, for not investigating this further but it’s feeling to me a little like a hard sell. So I said to the technician, “I’m guessing the research about 3-D mammography’s effectiveness vs 2-D isn’t definitive yet, or all the insurance companies would pay for it?” Which she denied. This much I recall very clearly. The evidence, she said, was there. Absolutely. Later, before she started the mammogram, she said, “Oh, you have x-and-such insurance. You’re probably not covered.”

So now I’m ticked AND…I had to think about it. I think I was ashamed. I think, for the first time in pursuit of good medical care, I was ashamed that a) my insurance coverage was lacking and b) I apparently didn’t care enough/couldn’t afford the best, most up-to-date treatment.

The first thing that occurred to me is that this is the kind of microaggression people are referring to. Nothing really overt; no one said, God, you’re cheap! or Man, you must be poor! But the implication was clear: that I was making a bad medical decision based on my inability or unwillingness to pay money out of my own pocket.

I think I was googling the research in the car on my phone before I even started on my way home. I should have done it before the appointment. I should have consulted my women’s health care provider before the appointment. So should you.

But I suspect you will find, as I have, no universally agreed-upon conclusions about 3- mammography.

Here’s what I ferreted out:

1. A definition of 3-D mammography, according to USA Today,

The technology, called tomosynthesis, provides three-dimensional images of the breast by using a technology similar to CT scans, or computed tomography, says Carol Lee, a radiologist at New York’s Memorial Sloan-Kettering Cancer Center and chair of the American College of Radiology’s breast imaging commission. The imaging machine moves around the breast in an arc, taking multiple X-rays that a computer forms into a 3-D image. The Food and Drug Administration approved tomosynthesis last year and it’s now used in 46 states, according to Hologic, which manufactures the machines.

2. A regular mammogram costs about $100;  3-D mammography (which is usually added, and not substituted) can cost from zero to $100 more. (For the record, this information was remarkably difficult to find.) When you have both procedures, you are exposed to slightly more radiation (USA Today).

3. My insurance doesn’t pay for it, because they consider it still “investigational.”

4. Medicare, starting in 2014, DOES pay for it.

5. Interestingly enough, in light of the general age of Medicare recipients, this is from the Cancer Prevention and Treatment fund website:

For most women, there is no reason to choose 2D digital mammography over film since it costs more. However, the study published in the New England Journal of Medicine suggests that for some women 2D digital images might be more accurate:

those who are younger than 50,
those who are pre- or peri-menopausal, and
those who have very dense breasts (dense breasts are more common in women under 50).
In those groups, which often overlap, some cancers were visible on 2D digital images that could not be found on film images.

More recent studies published in 2007, 2008, and 2011 found similar results: 2D digital mammography is more accurate than film for these specific groups of women.

6. Here’s another interesting take on Medicare funding of 3D mammograms, from an AARP website (an organization I might have thought instrumental in getting Medicare to pay for the procedure):

Yet many radiology centers promote the 3-D mammogram in gee-whiz terms, declaring it “a state-of-the-art technology,” “a tremendous advance in our ability to detect breast cancer on mammography,” “the latest breakthrough in mammography” or a “revolutionary screening tool.”

That sort of aggressive promotion may be necessary because the machine costs around $700,000 plus annual service fees. The extra amount patients pay help doctors recoup that expense.

7. OK, but what is the science? Is 3-D mammography more effective in detecting breast cancer than 2-D mammography? It turns out that’s a good question, with different answers from different sources.

The National Cancer Institute says

The accuracy of 3D mammography has not been compared with that of 2D mammography in randomized studies. Therefore, researchers do not know whether 3D mammography is better or worse than standard mammography at avoiding false-positive results and identifying early cancers.

The American Cancer Society says

[3D mammography] may let doctors see problem areas more clearly. This might lower the chance that you will need to be called back for another mammogram right away. It may also be able to find more cancers.

WebMD offers this headline, based on a study reported in the June 25, 2014 issue of the Journal of the American Medical Association (JAMA):

3D Mammograms May Improve Breast Cancer Screening
Higher detection rates, fewer false alarms seen with newer technology, study says

but when you read the entire WebMD piece, and if you can get through the original article in JAMA, it is revealed that “may,” is, in fact, the operative word.

The original JAMA article concludes: The addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. Further studies are needed to assess the relationship to clinical outcomes.

I think women should ask their own health care professionals. And maybe not the radiologists or mammogram technicians, who may have some financial stake in this, but our OB’s, gynecologists, our primary care professionals. Ask them if you should get a 3D mammogram. Come to their office or to your telephone call to them with knowledge of your own insurance company’s coverage. If your health care professional recommends 3D mammography, be sure to tell your doctor or nurse practitioner if your insurance won’t cover it.

If it’s a useful practice, let’s get it covered by insurance. Ask your health care provider how they can help with that, and lobby your insurance company when evidence becomes more clear. And until we know that it is or isn’t a useful practice, spend your own money on it as you wish. But don’t minimize the fact that many women are making the choice between 3D mammography and groceries, not, as in this radiologost-sponsored website, 3D mammograms and a mani-pedi.

6 Comments

  1. Well done, Donna! My father had breast cancer complete with a mastectomy and some oral chemo afterwards. Being the stubborn man he was, he refused the oral chemo. He recovered quite well and lived about 10 years more. Because of this in my family history, I am faithful with getting my annual mammograms. Because of the results from last year I will have either ultrasounds or the 3D option, due to dense tissue. Thanks for your article as I will clearly need to get prior authorization from my medical insurance carrier.

    Coffee soon?

  2. I like to think I take my health seriously and am knowledgeable, but so often I just check the box and do whatever the doctor says (whatever test, etc.) It’s so hard to stay up on everything and things change so quickly. It really is difficult to know what is necessary and what is over the top.

    I like the word micro-agression.

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