“I just can’t possibly have breast cancer because I just had a clean mammogram,” the Annandale nurse thought at the time. “That’s not how it works.”
Since that day 2 1
2 years ago, Tatusko has discovered that really can be how it works for women who, like her, have dense breast tissue.
Mammograms miss about 40 percent of cancers in women with dense breast tissue, medical experts say. What’s more, women with dense tissue are thought to be at significantly greater risk for breast cancer.
Other imaging techniques, such as MRIs and ultrasounds, can detect some tumors in dense tissue better than mammograms. But those tests have their own shortcomings. They are also very expensive and generally not covered by insurance, so doctors don’t use them for routine screenings.
Tatusko, now 56 and considered cancer-free after two years of aggressive treatment, is on a mission to change that. And partly because of her efforts, Virginia is set to become the third state, after Connecticut and Texas, to require radiologists to notify patients if they have dense breast tissue.
The Virginia House and Senate unanimously passed bills this General Assembly session requiring that radiologists put information about breast density in post-mammogram letters to patients.
“This is a common-sense measure to ensure women’s health,” said Taylor Thornley, a spokeswoman for Gov. Robert F. McDonnell (R), who intends to sign the legislation.
While enjoying overwhelming support now, the bills were met with behind-the-scenes resistance from Virginia radiologists. Concerned that women would be unduly alarmed, turned off from life-saving mammograms, and left footing the bill for unnecessary and expensive tests, they quietly lobbied against the legislation. They succeeded in changing the proposed language so that it would alert women to density but not suggest that they seek other tests.
Breasts are a mix of fatty and dense, glandular tissue. On a mammogram, the fatty tissue looks gray. The dense tissue looks white. So do cancers, which is why it is hard to spot tumors amid dense tissue and why additional testing can be useful for patients with dense breasts.
But radiologists are concerned that sending information about breast density to patients could cause problems, said Gilda Cardenosa, director of breast imaging at Virginia Commonwealth University Medical Center.
Cardenosa said she fears that even the toned-down legislation will cause women to lose faith in mammograms — “one of the best tests in medicine” — at a time when they’re already under fire. A federal health panel upended conventional breast-health wisdom in late 2009 by suggesting that women could wait until age 50, instead of 40, before getting mammograms, and then get them every other year instead of annually.
“It’s just one attack after another,” Cardenosa said. “Is mammography a perfect test? No. Neither is ultrasound. Neither is MRI.”
Breast-density notification bills are catching on three years after Nancy Cappello of Connecticut, whose late-stage cancer was missed by mammograms, successfully pushed legislation in her home state. Besides Virginia, nine other states are considering measures this year, said Cappello, who founded the nonprofit organization Are You Dense. Reps. Rosa L. DeLauro (D-Conn.) and Steve Israel (D-N.Y.) have legislation pending in Congress.
The measures have not sailed through everywhere. In October, California Gov. Jerry Brown (D) vetoed one, saying he was not sure the state should mandate such a thing.
The Virginia bills, proposed by Del. Robert D. “Bobby” Orrock Sr. (R-Caroline) and Sen. John S. Edwards (D-Roanoke), originally required radiologists to alert women if they have dense tissue and advise them that “supplementary screening tests may be beneficial.”
The language on other tests was removed at the urging of the Virginia chapter of the American College of Radiology and the Medical Society of Virginia. The final bills call for women to be told that they have dense tissue, “which can hide cancer or other abnormalities,” and that they should contact their doctor if they have questions.
Mammograms have been around since the 1950s; since at least the 1980s, reports from radiologists to referring doctors have noted tissue density. But that information has not been given to patients, in part because determining density is an inexact science, Cardenosa said. For the vast majority of women, the tissue is a mixture of fatty and dense, making determinations about density highly subjective, she said.
Her concern is that women who are told — perhaps inaccurately — that they have dense tissue will give up on mammograms. They may turn to MRIs and ultrasounds, which can catch some cancers but miss others, she said.
Then there is the matter of cost. Unlike mammograms, MRIs and ultrasounds for routine screenings usually aren’t covered by insurance. An ultrasound costs about $500. An MRI is $3,200 and up.
Connecticut’s law requires insurers to cover additional screenings with a doctor’s referral. The Virginia bills do not.
Cardenosa said insurance companies have refused to pay for such ultrasounds, even for a woman with dense tissue who already had breast cancer.
“If the insurance companies were willing to pay for MRIs on everybody, I would be the first person to jump up and cheer,” she said. “But will our health system really absorb $3,200 [per patient]? We’ve got limited resources. ”
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