From the July 2022 issue of HealthCare Business News magazine
Consideration should not only be given to how a woman weighs the trade-off between a false positive (resulting in an unnecessary callback) and detecting cancer, but also to the costs of screening. Insurance coverage for supplemental screening varies by level of medical necessity and insurance carrier, resulting in it not always being covered by a woman’s insurance. The cost of care is another known driver of health disparities in the U.S. Women should not learn of this variation in insurance coverage through the form of a surprise bill only after imaging is performed.
Women of lower socio-economic status may not have as many resources to engage in decision-making with their clinicians or to pay for supplemental imaging. It is well documented that rural patients have a higher burden to accessing care (cost and time) than their urban counterparts, and black women have a higher breast cancer mortality rate than white women. Careful attention is needed to ensure that breast density notifications have their intended beneficial effect and do not create further disparities in care.
Addressing how clinics effectively incorporate breast density conversations into routine clinical care is an area that needs more research, but imbedding reminders and decision support tools in electronic medical records (EMRs) can prompt needed conversations at the point of care and has been shown to improve patient outcomes. Including these conversations in routine care will help to ensure that women understand notifications and what their density means about their personal risk of breast cancer. Discussions about cancer risk should not only include breast density but also other risk factors such as age and family history. A study by Kerlikowske et al. showed that identifying women for supplemental screening by considering both breast density and breast cancer risk is better at optimizing the balance of benefits and harms than when only breast density is considered. One of multiple tools available for assessing breast cancer risk is the Breast Cancer Surveillance Consortium (BCSC) 5-year risk calculator, which has been externally validated in the Mayo Mammography Health Study. Unless such tools are embedded into EMR systems, clinicians must have knowledge of which tools to use and take initiative to access them online or through external applications.
Sending women notifications about their breast density is a good first step toward reaching one of the FDA’s specified aims for the new MQSA rule of “improv[ing] the delivery of mammography services by strengthening the communication of healthcare information; [and] allowing for more informed decision-making by patients and providers.” But notifications alone do not appear to reach this goal for all women. Our recent research on women’s knowledge of breast density suggests that some women are misunderstanding information about their density or are not having conversations with their providers about its implications. Clinicians need tools guided by evolving evidence to effectively engage in conversations with women about breast density, breast cancer risk, and supplemental screening. With national breast density legislation pending, the time is now to implement tools in routine clinical care to ensure density notification results in the intended positive outcomes.
About the author: Rebecca E. Smith is a Ph.D. student in the Dartmouth Institute for Health Policy and Clinical Practice’s doctoral program and a research project manager at Dartmouth Hitchcock Medical Center. Previously, for a combined 10 years, she was a research fellow and project manager in the Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth.
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