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Some Older Women Need Extra Breast Scans. Why Won’t Medicare Pay?

Mammograms may miss tumors in women with dense breast tissue. So for these patients, doctors often include a second scan – an ultrasound, for example, or an MRI – which is more likely to detect cancers at an early stage.

But some older patients find themselves faced with an unexpected twist. Although many women consider the additional scan a form of routine prevention, Medicare will not pay for it and some patients face a hefty bill.

Joellen Sommer, 66, who lives in Manhattan, went for her annual breast cancer screening in March. But clinic staff said that while her mammogram would be fully covered by Medicare, a so-called supplemental ultrasound was not.

Ms. Sommer has dense breasts and a family history of breast cancer. She said she has had mammograms and ultrasounds throughout her adult life. “I just don’t understand how a diagnostic test that has been recommended for years is suddenly no longer covered by Medicare,” she said.

“My mother had breast cancer, my aunt had breast cancer – I guess that’s not enough,” she added. “I wonder if this was a test for men, if the same problem would arise.”

Lenox Hill Radiology in New York has begun warning patients that if they are insured by Medicare, they may have to pay up to $450 if they undergo a breast ultrasound, even if the breast tissue is known to be dense and the additional analysis is required. performed on the same day as a screening mammogram.

A fact sheet provided to doctors states that Medicare covers breast ultrasound in limited circumstances, such as “to evaluate palpable or nonpalpable breast masses, ambiguous mammograms, and other signs or symptoms suggestive of breast cancer.” breast”.

Guidelines on when and how often to screen for breast cancer have changed over the years, but mammograms, which use low-dose X-rays to detect lesions, have long been the gold standard for early detection.

But mammograms can’t actually “see” tumors in dense breast tissue; both appear white on an x-ray. And dense breasts are not uncommon: While density decreases with age, nearly half of women ages 40 and older who get a mammogram have dense breast tissue, according to the National Cancer Institute.

Breast tissue is considered dense when it contains more fibrous and glandular tissue and less fatty tissue.

Starting in September, all mammography centers in the United States will be required to inform patients undergoing breast cancer screening if they have dense breasts. The effort to call attention to the shortcomings of mammograms in these patients was started by women whose own cancers were detected late, despite regular mammogram exams.

Dense breast tissue is itself a risk factor for breast cancer. According to studies, women with extremely dense breasts are twice as likely as those who have what is called “scattered dense tissue” or dense tissue here and there in the breast.

Advocates say that for women with dense breast tissue, mammograms alone constitute “incomplete screening,” and some scientists agree. Dr. Dorraya El-Ashry, scientific director of the Breast Cancer Research Foundation, said an additional ultrasound is the current standard of care for secondary screening for dense breasts.

“In women with the densest breasts, mammograms will miss about half of the cancers present, or half,” said JoAnn Pushkin, executive director of DenseBreast-info, an educational group.

The group’s most frequently asked questions come from women trying to get additional exams or find out why they weren’t covered by insurance, Ms. Pushkin said.

“That’s a lot of cancers left on the table and a missed opportunity to detect them as early as possible, when they are most treatable and most survivable,” she added.

The organization supports the Find It Early Act, legislation proposed by Rep. Rosa DeLauro, Democrat of Connecticut, and Rep. Brian Fitzpatrick, Republican of Pennsylvania. This measure would ensure that all health insurance plans cover breast screening and diagnostic imaging, including mammograms, ultrasounds and MRIs, without cost sharing.

A spokeswoman for the federal Centers for Medicare & Medicaid Services said their policies have not changed: Medicare covers 100 percent of annual radiology screening for women ages 40 and older, as part of preventative care.

But the agency distinguishes between mammograms and other screening tests, such as ultrasounds, and they are billed as diagnostic tools, the spokeswoman said in an email.

And there is no universal agreement on the benefit of alternative screening for women with dense breasts. The American College of Radiology says 3D mammography increases the number of cancers visible without additional testing, and that ultrasound and MRI can help detect cancers not visible on a mammogram.

But neither the American College of Obstetricians and Gynecologists nor the U.S. Preventive Services Task Force have approved additional breast cancer screening methods for patients with dense breast tissue. Data from clinical trials are insufficient to do this, the groups say.

There are also disadvantages associated with additional screening methods, such as a high rate of false positives on ultrasound, which cause anxiety and unnecessary follow-up care, and the high costs associated with MRI scans.

But in a letter to the task force last year, Ms. DeLauro and Rep. Debbie Wasserman Schultz, Democrat of Florida, said several of the group’s recommendations had put women’s lives at risk, including the incapacity of the working group to “recognize the significant body of evidence”. support additional screenings” for patients with dense breasts.

News Source : www.nytimes.com
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