How conflicting government messages about annual screening could affect the bottom line for imaging centers.

When the US Preventive Services Task Force (USPSTF) announced its controversial mammography recommendations in mid-November, Montclair Breast Center in Montclair, NJ, sprang into action. Within just a few days, the facility sent out an e-mail blast to all patients detailing the center?s response to the guidelines and stressing the importance of annual mammography in saving women?s lives.

The center?s response adamantly disagreed with the task force?s recommendations?including the suggestion that women between the ages of 40 and 49 do not benefit from annual mammography screenings?and summarized the scientific data supporting yearly exams. The idea was to prevent mixed messages from confusing patients about the value of annual screenings, and to encourage them to continue to come in for their mammograms every year.

Rose Heller-Savoy, MD, director of mammography services for Montclair Breast Center

?I can?t tell you how many wonderful responses we received thanking us and in full agreement with us,? said Rose Heller-Savoy, MD, director of mammography services for Montclair Breast Center. ?These women are planning to continue to have their yearly mammography, regardless of what these guidelines say.?

Of course, Heller-Savoy notes that a patient?s resolve will be put to the test if insurance carriers opt to drop mammography coverage based on the USPSTF guidelines.

?If it?s taken a step further and coverage is decreased, then it?s going to put many patients in a very hard position, because they may want to get their mammography, but their insurance won?t cover it,? she said.

The economic impact that the USPSTF guidelines will ultimately have on imaging centers remains unclear?especially in light of the government?s own mixed messages on mammography. On December 3, for example, the US Senate passed an amendment to its health care bill that specifically ignores the USPSTF guidelines and would require coverage for yearly mammography screenings after the age of 40.

While the Senate?s vote is certainly a hopeful sign for imaging centers, facilities could still suffer a financial backlash in the wake of the USPSTF guidelines.

?I think fewer and fewer women will come for their mammograms,? said Randy Hicks, MD, MBA, president of Regional Medical Imaging, who has spent close to $2 million updating his five outpatient imaging centers in mid-Michigan to all-digital mammography. ?That?s a problem in that we?ve all ramped up a great deal for the digital world. If everybody in the country is doing that, and we have a setback in the amount of mammography done, then, of course, that?s going to hurt.?

A Tough Outlook

Currently, the biggest threat to patient volume for imaging centers offering mammography is confusion over the USPSTF guidelines. For example, women who are putting off their annual mammograms may now feel justified in waiting another year or even longer?which could put their lives at risk, says Heller-Savoy.

?The USPSTF went after all parts of the evaluation?clinical breast exam, self-breast exam, and mammography,? she said. ?It?s as if they don?t want a woman in the 40 to 49 age range to think of her breasts at all, in any way.?

While most of the media attention on this controversy has centered on the implications for women in their forties, Heller-Savoy notes that she is equally disturbed by the task force?s recommendation for women to be screened only biennially between the ages of 50 and 74.

?I have seen many cancers develop in 1 year,? she said. ?To give cancer 2 years to grow before looking for it is absurd.?

The USPSTF also does not recommend mammography for women over age 74, but Heller-Savoy notes that women in this age range can still benefit from screening, as long as they are in good health.

If the USPSTF guidelines were followed to the letter, then imaging centers would face a dramatic decrease in mammography volume across the entire age spectrum of women. For centers that focus on women?s health and breast imaging, especially, this could be a devastating blow.

?For breast imaging centers specifically, we?re always fighting an uphill battle because reimbursement is really low compared to our hard costs, such as the cost of equipment and technologists,? said Marla Lander, MD, founder of Solis Breast Health Center in Indio, Calif. ?It?s such a narrow margin that most places will operate in the red. The centers that survive the best are either general imaging centers or multispecialty groups, or are part of a hospital radiology group where they?re making up for mammography being the loss leader in other areas, such as interventional radiology.?

If more breast imaging centers are forced to close, Lander adds that access to timely care will become a greater issue for patients.

?The sad part is, if you look at what?s happening across the country, most centers are 1 month or 2 months behind?they can?t keep up with their screening volumes,? she said. ?So, if we start closing doors on more centers, that?s going to become more and more of a problem.?

Lander notes that some breast imaging centers may be tempted to diversify into other areas of imaging in order to keep their doors open?but she cautions against this impulse. Not only is it costly to bring on new equipment and new staff trained in other specialties, but it also means that physicians who are not trained in breast imaging will be reading mammograms and that breast imaging specialists will likely be forced to spend more time in other areas as well.

?There are so few people who are well trained in breast imaging that you hate to divert their energy away from what they?re best at,? she said. ?So, there?s a temporary bandage that can be put on, but it?s not really the direction that things should go from a health perspective for the population.?

While Heller-Savoy agrees that reduced mammography volumes could take a heavier toll on breast imaging centers than on those that do not specialize, she notes that a loyal, well-informed patient base could go a long way toward keeping these centers afloat.

?Typically, patients who are choosing to go to a center that is dedicated to breast imaging make that choice because they feel that that?s where they?re going to get the most state-of-the-art care and the most dedicated people to breast disease,? Heller-Savoy said. ?So, already they?re not the kind of patients who would be ambivalent about mammography.?

For imaging centers that do not specialize in breast imaging per se but still offer mammography, Hicks notes that diversification is key?but it?s just as important to be prudent about spending.

?There are a lot of unknowns out there about what?s going to happen with anything in imaging today,? he said. ?You have to be judicious and just take your time to decide how you?re going to spend your money because it?s a tough, tough world out there.?

A Better Test?

Mammography has long been the standard of care for screening women for breast cancer, but even mammography advocates acknowledge that there are limitations with this screening tool. False positives are common, especially among women with dense breast tissue, and often lead to biopsies and further testing.

The USPSTF has been criticized by the medical community for citing the emotional implications of false positives as a motivating factor for suggesting that women wait until age 50 to begin regular mammography screenings.

?Ask any woman?she would rather go through that emotional distress than not know whether she has breast cancer,? Hicks said. ?We still believe that mammography should be performed because we have so many cases of 40- to 49-year-old women with cancer.?

Still, Hicks acknowledges that false positives on mammograms are common for women in their forties, who often have dense breast tissue. This is why he believes breast-specific gamma imaging (BSGI), which is not affected by breast density, could be an excellent first screening tool for women with dense breast tissue. Mammography would then be used as an adjunctive tool in these cases, he notes.

?If we used BSGI in the dense-breasted population, which is the 40- to 49-year-old group, I think we would actually set new standards for finding breast cancer in those women and lower the number of biopsies that we do,? he said.

This is more easily said than done, Hicks acknowledges. Currently, BSGI, MRI, and breast ultrasound are considered adjunctive tools to mammography?and elevating the status of any of these modalities for breast cancer detection would require a sea change within the medical community. It would also require expensive overhauls for imaging centers, many of which have already invested millions of dollars in digital mammography technology.

?It would take a huge momentum to change, and that?s very difficult to do in an ingrained society of medicine,? Hicks said.

Lander notes that while tools such as BSGI are effective when used in conjunction with mammography, no other test has yet been scientifically proven to be as effective as mammography for breast-cancer screening.

?BSGI, MRI, and ultrasound are all great tools, but they?re adjunctive tools to mammography,? she said. ?None of them have had the blanket testing and the proof that mammography has had. All of them are more expensive, and none of them are as good at detecting cancer globally on women.?

Of course, under the USPSTF guidelines, it is likely that no other screening test for breast cancer would be covered for women ages 40 to 49 anyway.

?If the government or the insurance companies are not even going to pay for mammography, they?re surely not going to pay for the additional tests,? she said.

Lander stresses that mammography is still the gold standard of screening tools and is the key to early breast-cancer detection and intervention.

?I think one of the short-sighted things with the government trying to decrease the monies in screening is that they?re going to set us back,? she said. ?We?re going to have more advanced breast cancers, and it is much more expensive to treat runaway, invasive, advanced cancers than it is to treat little screen-detected ones by removing them surgically.?

A Call to Action

For imaging centers, the key to keeping their doors open is educating patients, referring physicians, and the public at large about the value of mammography as a screening tool for breast cancer.

For Lander, the current controversy goes deeper than the USPSTF recommendations alone, but points to a larger knowledge gap when it comes to mammography. This is why she suggests a grassroots effort to educate the public?and especially referring physicians and patients?about the benefits of mammography screening.

?Even without these task force recommendations, 30% to 40% of women in the country who qualify for mammography aren?t coming in to get them,? she said. ?So, I really think education is key.?

Whether you are talking to patients or referring physicians, getting the word out about survival statistics is a great place to start.

?The most important message to get across is that mammography screening is the best medical screening test that we currently have as physicians around the globe?as proven scientifically,? Lander said. ?If we do yearly screening of women starting at the age of 40, we can reduce breast cancer mortality by 50%. It?s huge.?

Lander adds that the task force also called for the cessation of screening women in the 40- to 49-year-old group, unless they are ?high risk.? It is important to note that only 15% of breast cancer patients come from high-risk families, she says.

?That means that you?re excluding 85% of the women who would be diagnosed with breast cancer if you recommend screening only the high-risk ones,? Lander said.

Here are a few other ways imaging centers can get the word out to patients and referring physicians about the benefits of mammography screening:

• Talk to your patients. It?s a safe bet that most of your patients don?t know what the debate about the USPSTF mammography guidelines means for their care. Take time during their visits to your center to give them the information they need to make informed decisions. ?A lot of the women are very nervous about it,? Hicks said. ?They don?t know what to do, and they?re very confused. I spend a lot more time talking to patients and teaching them one on one now.?

• Put it in writing. Follow Montclair Breast Center?s example, and send a written response to the USPSTF guidelines to your patients, referring physicians, and even local media outlets. ?I do think that some of the information out there in the press has been a little confusing,? Heller-Savoy said. ?So, I think the first thing a center should be doing is getting their own message out as to what they feel is best.?

• Make it personal. Hicks notes that many referring physicians are also confused about the guidelines and call the imaging center for clarification. When making the case for mammography to a referring physician, Hicks makes sure to give real examples of patients in their forties and fifties who have been affected by breast cancer. ?It?s not like you have to go back into your archives to look for a story that?s just a heartbreaker,? Hicks said. ?We have them every day.?

• Be state-of-the-art. Heller-Savoy notes that imaging centers have to offer patients a reason to seek out their facilities for mammography services. This means hiring fellowship-trained imagers and having the latest technology, such as image-guided biopsies, available on site. Talk up these services to patients and referring physicians to make sure they understand how important they are to providing excellent care. ?If centers are giving the most advanced care, then patients will always want to come to them,? she said.

In these uncertain times, imaging centers can?t afford to let their mammography volumes slip?which is why Heller-Savoy recommends combining targeted patient education with state-of-the-art breast imaging services.

?I believe that the more informed patients are, the more likely they are going to go to centers that either are dedicated or at least have dedicated, fellowship-trained staff who are doing breast imaging and intervention,? Heller-Savoy said. ?So, the best way for a center, from an economic perspective, to keep their revenue from breast imaging is to make sure that they?re doing it well.?

Ann H. Carlson is a contributing writer for Axis Imaging News.