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Can there be too much cancer screening? Concord Imaging Center, Sen. Ayotte tackle the question

  • Chief mammographer Melissa Sargent pulls up example digital images from a new machine that provides breast tomosynthesis, or 3D breast imaging, at Concord Imaging Center on Tuesday, Jan. 5, 2016. The technology renders multiple images from multiple layers of tissue into a three dimensional representation.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff

  • Chief mammographer Melissa Sargent pulls up example digital images from a new machine (seen in the background) that provides breast tomosynthesis, or 3D breast imaging, at Concord Imaging Center on Tuesday, Jan. 5, 2016. The technology renders multiple images from multiple layers of tissue into a three dimensional representation.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff

  • Chief mammographer Melissa Sargent pulls up example digital images from a new machine (seen in the background) that provides breast tomosynthesis, or 3D breast imaging, at Concord Imaging Center on Tuesday, Jan. 5, 2016. The technology renders multiple images from multiple layers of tissue into a three dimensional representation.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff

  • Chief Mammographer Melissa Sargent shows example images from a machine that provides 3-D breast imaging at Concord Imaging Center.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff

  • A new machine providing breast tomosynthesis, or 3D breast imaging, is seen at Concord Imaging Center on Tuesday, Jan. 5, 2016. The technology renders multiple images from multiple layers of tissue into a three dimensional representation.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff

  • Chief Mammographer Melissa Sargent pulls up example digital images from a new machine (seen in the background) that provides breast tomosynthesis, or 3-D breast imaging, at Concord Imaging Center on Tuesday. The technology renders multiple images from multiple layers of tissue. ELIZABETH FRANTZ / Monitor staff

  • A new machine providing breast tomosynthesis, or 3D breast imaging, is seen at Concord Imaging Center on Tuesday, Jan. 5, 2016. The technology renders multiple images from multiple layers of tissue into a three dimensional representation.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff

  • A new machine providing breast tomosynthesis, or 3-D breast imaging, is seen at Concord Imaging Center on Tuesday.The technology renders multiple images from multiple layers of tissue into a three dimensional representation.(ELIZABETH FRANTZ / Monitor staff) ELIZABETH FRANTZ / Monitor staff



Thursday, January 07, 2016
With Concord Hospital’s new 3-D Breast Cancer Imaging as background and a new law co-sponsored by U.S. Sen. Kelly Ayotte about insurance for mammograms as foreground, the complicated debate over how much cancer screening is proper came to town Tuesday morning.

Ayotte’s legislation and visit to the Concord Imaging Center was prompted by a recommendation from the Preventive Service Task Force, an advisory arm of the federal Department of Health and Human Services.

That group, formed in 1984 to help guide health care practitioners, proposed downgrading its recommendation for breast cancer screenings for women aged 40 to 49 who are not at high risk of getting the disease.

Based on past guidelines, doctors have long recommended that most women over the age of 40 get an annual breast exam or mammogram. But the Preventive Task Force said a number of studies show that annual mammograms in the 40-49 age group lead to excessive “false positive” findings, as well as the discovery of tissue anomalies that aren’t necessarily dangerous but nonetheless get treated, causing more harm than good to the population as a whole.

This recommendation is controversial among patient advocates and within the medical community, partly because it would have allowed insurance companies and federal programs such as Medicare and Medicaid to no longer cover the cost of mammograms for most women between 40 and 49.

This would likely lead most patients to cut back on, or eliminate, their breast cancer screenings before age 50.

“If you give them an out, tell them there’s a debate about whether it’s necessary or not, they’re not going to go,” said Doug Ewing, a radiologist in the Concord Imaging Center at Concord Hospital. He and radiologist Mark Hadley went with Ayotte on a tour of the center’s digital tomosynthesis machines, often called 3-D imaging, which went online in the fall. The system is a step up from digital mammography.

The possibility of cutbacks in insurance coverage raised alarm among many, including Ayotte, who is 47. She and Barbara Mikulski, a 79-year-old Democratic senator from Maryland, co-sponsored a bill that put the task force recommendations on hold for two years while the issue is re-examined. The law was passed at the end of the year as part of the omnibus spending bill.

“This is a very significant shift,” Ayotte said. “This recommendation was made with no one who had a background in imaging, radiology or even, as I understand it, oncology. . . . I would like to see more transparency in the task force process.”

Ewing said he thought the recommendation was flawed because studies are based on pre-digital systems.

“The technology is getting so much better. Most of those studies that are the cornerstone of reaching this conclusion are based on film technology,” he said.

Ayotte told the group she had heard from people throughout New Hampshire who were concerned about the loss of insurance coverage for breast cancer screenings, including one story in particular that hit home.

“My hairdresser Deb, she works at Posh in Concord and she has done my hair for over a decade. When she was 44 years old, she had a mammogram. They detected breast cancer, not something that would (be found) on a manual exam. They were able to treat it,” Ayotte said during a discussion at Concord Hospital on Tuesday morning.

“I’ve heard literally dozens of stories from throughout New Hampshire, but when you’re sitting in the chair and your hairdresser tells you – I remember all she had to go through with her family. Had she not had the recommendation to get that annual mammogram, I don’t think she’d have done it,” she said.

The task force recommendation is part of a wider re-examination of cancer screenings that has often been controversial. The American Cancer Society has also cut back slightly on its breast cancer screening recommendations for women, although it has not gone as far as the Preventive Task Force, and last year the task force stopped recommending routine PSA screening for prostate cancer in men, producing considerable debate.

Notably, Gilbert Welch at the Geisel School of Medicine at Dartmouth College argued that too much screening is done for many diseases, particularly cancer, leading to higher health care costs, unnecessary stress and trauma, as well as unnecessary treatment or surgery. All of this, he has argued in books and lectures, often outweighs the benefits of finding some diseases early.

“I understand that argument, but I just don’t see it,” said Hadley at Concord Imaging Center. “There are risks (to screening) – stress, (over-)treatment – they’re bad, but they’re not as bad as dying. The downside would have to be pretty big when you’re talking about saving lives.”

Hadley and Ewing told Ayotte that the drawbacks are being lessened, partly by procedures such as more accurate risk assessment, based on factors like tissue density and lifestyle that reduce the likelihood of unnecessary action, and partly by improved procedures that cut the time between diagnosis and post-treatment plastic surgery, reducing it from months to weeks.

Hadley said 3-D imaging also reduced the number of callbacks, in which patients must repeat the mammography procedure because of uncertain about masses seen in images from the first session. Although data are still sketchy because the system has not been used for long, Hadley said the Concord system had reduced the callback rate to about 6 percent, from a rate with digital mammographs of between 8 percent and 12 percent.

Cost remains an issue. Larry Glass, business manager for the Concord Imaging Center, said that a basic screening, including digital mammogram, costs an average of $265, while digital tomosynthesis adds an average of $123 to the cost.

Medicare reimburses that extra amount of 3-D Breast Imaging, but Anthem Blue Cross, the state’s largest private insurer, does not at the moment consider it part of the “standard of care” that must be reimbursed, Glass said.

Concord Imaging Center has been absorbing the extra $123, a total of “very roughly” a quarter-million dollars since the system began operating in the fall, Glass said.

“This is really a fluid situation. We didn’t want to drop it on the backs of our patients,” Glass said.

Concord Imaging Center plans to introduce molecular breast imaging within the next six months, another technology that will add to the ability to be specific about tumors and other masses.

Still, Hadley said, screening will always be imperfect.

“We’re not at the point where we can tell which cell will hurt you and which won’t,” he said. “We can’t say this cell is the one that is going to be malignant. They’re applying that sort of science in labs, but we’re not able to do it in medicine. Some day we will, perhaps 10 years, but not yet.”



(David Brooks can be reached at 369-3313, dbrooks@cmonitor.com, or on Twitter @GraniteGeek.)

With a new 3-D breast cancer imaging machine as background and a new law co-sponsored by U.S. Sen. Kelly Ayotte about insurance for mammograms as foreground, the complicated debate over how much cancer screening is proper came to town Tuesday morning.

Ayotte’s legislation and visit to the Concord Imaging Center was prompted by a recommendation from the Preventive Service Task Force, an advisory arm of the federal Department of Health and Human Services.

That group, formed in 1984 to help guide health care practitioners, proposed downgrading its recommendation for breast cancer screenings for women aged 40 to 49 who are not at high risk of getting the disease.

Based on past guidelines, doctors have long recommended that most women over the age of 40 get an annual breast exam or mammogram. But the Preventive Task Force said a number of studies show that annual mammograms in the 40-49 age group lead to excessive “false positive” findings, as well as the discovery of tissue anomalies that aren’t necessarily dangerous but nonetheless get treated, causing more harm than good to the population as a whole.

This recommendation is controversial among patient advocates and within the medical community, partly because it would have allowed insurance companies and federal programs, such as Medicare and Medicaid, to no longer cover the cost of mammograms for most women between 40 and 49.

This would likely lead most patients to cut back on, or eliminate, their breast cancer screenings before age 50.

“If you give them an out, tell them there’s a debate about whether it’s necessary or not, they’re not going to go,” said Doug Ewing, a radiologist in the Concord Imaging Center. He and radiologist Mark Hadley went with Ayotte on a tour of the center’s digital tomosynthesis machines, often called 3-D imaging, which went online in the fall. The system is a step up from digital mammography.

The possibility of cutbacks in insurance coverage raised alarm among many, including Ayotte, who is 47. She and Barbara Mikulski, a 79-year-old Democratic senator from Maryland, co-sponsored a bill that put the task force recommendations on hold for two years while the issue is re-examined. The law was passed at the end of the year as part of the omnibus spending bill.

“This is a very significant shift,” Ayotte said. “This recommendation was made with no one who had a background in imaging, radiology or even, as I understand it, oncology. . . . I would like to see more transparency in the task force process.”

Ewing said he thought the recommendation was flawed because studies are based on pre-digital systems.

“The technology is getting so much better. Most of those studies that are the cornerstone of reaching this conclusion are based on film technology,” he said.

Ayotte told the group she had heard from people throughout New Hampshire who were concerned about the loss of insurance coverage for breast cancer screenings, including one story in particular that hit home.

“My hairdresser Deb, she works at Posh in Concord and she has done my hair for over a decade. When she was 44 years old, she had a mammogram. They detected breast cancer, not something that would (be found) on a manual exam. They were able to treat it,” Ayotte said during a discussion at Concord Imaging Center on Tuesday morning.

“I’ve heard literally dozens of stories from throughout New Hampshire, but when you’re sitting in the chair and your hairdresser tells you – I remember all she had to go through with her family. Had she not had the recommendation to get that annual mammogram, I don’t think she’d have done it,” she said.

The task force recommendation is part of a wider re-examination of cancer screenings that has often been controversial. The American Cancer Society has also cut back slightly on its breast cancer screening recommendations for women, although it has not gone as far as the Preventive Task Force. Last year, the task force stopped recommending routine PSA screening for prostate cancer in men, producing considerable debate.

Notably, Gilbert Welch at the Geisel School of Medicine at Dartmouth College argued that too much screening is done for many diseases, particularly cancer, leading to higher health care costs, unnecessary stress and trauma, as well as unnecessary treatment or surgery. All of this, he has argued in books and lectures, often outweighs the benefits of finding some diseases early.

“I understand that argument, but I just don’t see it,” Hadley said. “There are risks (to screening) – stress, (over-)treatment – they’re bad, but they’re not as bad as dying. The downside would have to be pretty big when you’re talking about saving lives.”

Hadley and Ewing told Ayotte that the drawbacks are being lessened, partly by procedures such as more accurate risk assessment, based on factors like tissue density and lifestyle that reduce the likelihood of unnecessary action, and partly by improved procedures that cut the time between diagnosis and post-treatment plastic surgery, reducing it from months to weeks.

Hadley said 3-D imaging also reduced the number of callbacks, in which patients must repeat the mammography procedure because of uncertain about masses seen in images from the first session. Although data are still sketchy because the system has not been used for long, Hadley said the Concord system had reduced the callback rate to about 6 percent, from a rate with digital mammographs of between 8 percent and 12 percent.

Cost remains an issue. Larry Glass, business manager for the Concord Imaging Center, said that a basic screening, including digital mammogram, costs an average of $265, while digital tomosynthesis adds an average of $123 to the cost.

Medicare reimburses that extra amount of 3-D Breast Imaging, but Anthem Blue Cross, the state’s largest private insurer, does not at the moment consider it part of the “standard of care” that must be reimbursed, Glass said.

Concord Imaging Center has been absorbing the extra $123, a total of “very roughly” a quarter-million dollars since the system began operating in the fall, Glass said.

“This is really a fluid situation. We didn’t want to drop it on the backs of our patients,” Glass said.

Concord Imaging Center plans to introduce molecular breast imaging within the next six months, another technology that will add to the ability to be specific about tumors and other masses.

Still, Hadley said, screening will always be imperfect.

“We’re not at the point where we can tell which cell will hurt you and which won’t,” he said. “We can’t say this cell is the one that is going to be malignant. They’re applying that sort of science in labs, but we’re not able to do it in medicine. Some day we will, perhaps 10 years, but not yet.”



(David Brooks can be reached at 369-3313, dbrooks@cmonitor.com, or on Twitter 
@GraniteGeek.)