3 juin, 2007 19:40
Finding ways to find cancer
In-Forum (subscription) - Fargo,ND,USA
He said BSGI has found cancer in cases it otherwise wouldn't have been detected, including
patients with breast implants or dense tissue. ...
"Even knowing where the tumor was they wouldn’t have been able to identify it. I think if someone has dense breasts they should at least have the option of the MRI. For people like me, there needs to be more. There needs to be another method."
Judy Carson
West Fargo cancer patient
Within six weeks, Judy Carson went from being told her mammogram was all clear to having surgery to remove a cancerous lump in her left breast.
Since her breast cancer diagnosis, Carson has made it her crusade that women like her can receive more accurate diagnostic screenings, such as magnetic resonance imaging, or MRI, of the breast.
Carson, 46, of West Fargo, has been told she has solid, dense breast tissue, which can make mammography an unreliable detection tool.
She has no family history of breast cancer and said she always trusted her mammograms until she found the lump during a self-exam three weeks after her February appointment.
The 1.9 cm mass didn’t show up on the mammogram, but was confirmed by an ultrasound and easily seen on an MRI ordered by the oncologist, she said.
"Even knowing where the tumor was they wouldn’t have been able to identify it," on the mammogram, said Carson, who works as an
X-ray technician. "I think if someone has dense breasts they should at least have the option of the MRI.
"For people like me, there needs to be more. There needs to be another method."
New screening technologies like the breast MRI and BSGI – breast-specific gamma imaging – are able to detect cancerous breast tissue more often. But their higher costs and potential consequences have yet to be fully compared to their advantages, some experts say.
Insurance question
It’s an issue fresh in the minds of local hospitals, as well as Blue Cross Blue Shield North Dakota.
The insurance company is convening an advisory panel of breast imaging experts to evaluate its policy on reimbursing screening procedures.
Blue Cross Blue Shield’s current policy doesn’t reimburse MRI of the breast for patients with dense breasts.
"We’re in the process of just re-evaluating this policy with the availability of new technology, even though the policy is just a year old," said Dr. Jon Rice, senior vice president and chief medical officer. "Areas like this are in a state of flux."
In a May 14 letter to Rice, North Dakota Insurance Commissioner Jim Poolman requested Blue Cross Blue Shield assess the effectiveness of these procedures and possible cost savings of early detection.
Poolman had been approached by Carson and other women with similar concerns.
"Anytime that women can be diagnosed earlier with potential breast cancer, the better off we all are," Poolman said. "I am not the expert in proving these are foolproof and that much more effective, but if they are proven so, companies ought to take a look at covering them."
Rice responded in a May 21 letter that there have been no long-term studies to demonstrate improved outcomes or cost effectiveness.
"I’ve not heard any recommendations from our provider community that suggest changes or inappropriateness," Rice said in a recent telephone interview.
Blue Cross provides benefits for MRI of the breast for some patients. In March, the American Cancer Society released new MRI screening guidelines, recommending women who have a 20 percent or greater lifetime risk of developing breast cancer receive an annual mammogram and MRI.
Women at a moderately increased risk should talk to their doctors about adding an MRI screening to their yearly mammogram, the cancer society said. Yearly MRIs are not recommended for women with a lifetime risk less than 15 percent. This risk is based on a number of factors, including genetic mutation, family history, age of first menstruation, previous breast biopsies and age of first live birth, said Dr. Anu Gaba, a medical oncologist and hematologist with MeritCare’s Roger Maris Cancer Clinic in Fargo.
Gaba said there would be a danger in applying the MRI to all women. MRIs have a higher rate of false positive diagnoses, possibly setting off a trail of further tests and biopsies, and causing unwarranted anxiety.
"I think the medical community understands we want to screen women better for breast cancer but at the same time we want to be cautious of it," she said. "We want to make sure the benefits outweigh the harm of the screening test."
Possible alternative?
Breast-specific gamma imaging may offer the benefits society wants without the costs, said Dr. Ted Fogarty, radiologist at MedCenter One Health Systems in Bismarck and chairman of the University of North Dakota School of Medicine’s Department of Radiology.
MedCenter One has been using BSGI since the beginning of 2006. It is used for a second screening, in cases of abnormal mammograms, clinical findings or high-risk patients, Fogarty said.
He said BSGI has found cancer in cases it otherwise wouldn’t have been detected, including patients with breast implants or dense tissue.
It also has reduced the number of biopsies, as masses that previously would have been operated on are shown to be benign.
"It gives you functional information about what those tissues are doing, how they’re behaving," Fogarty said. "I think this is the technology piece everybody’s been looking for for years."
He said BSGI fills the gap between questionable mammograms and the more expensive MRIs, especially in patients with dense breasts. These women are more like to develop cancer, and are more likely to have it be missed in a screening, Fogarty said.
"Everybody in mammography is clamoring for an alternative for dense breasts. This is it," he said.
Blue Cross covers breast-specific gamma imaging when mammography or ultrasound is inconclusive, including cases of dense breasts, implants and scarring after treatment for cancer.
Neither MeritCare nor Innovis in Fargo offers BSGI. Spokespersons at both hospitals said it is something they’ve contemplated, but are awaiting scientific proof of its effectiveness.
"We just want to make sure the research data supports the direction we move in," said Todd Forkel, director of radiology at Innovis. "It’s so easy to get caught up in the marketing piece of it rather than the clinical relevance."
In the meantime, Carson will begin her fourth round of chemotherapy Tuesday.
She said she doesn’t want to diminish the importance of mammograms, but she encourages women to perform regular self-exams. That was how she found her cancer, early enough to have a good prognosis.
"There’s so many more women out there, if they don’t do their self checks, they can’t rely on the mammogram because they’re not fool-proof," Carson said.
"Until we can get other screening methods available with insurance coverage that really is our only option."
Glossary
- Breast-specific gamma imaging (BSGI): A molecular breast imaging procedure. A small amount of a radioactive tracing agent is injected into the patient and absorbed by the body's cells. The agent emits invisible gamma rays, detected by a specially designed camera and translated into a digital image. Also known as a gammagram.
- Magnetic resonance imaging (MRI): A procedure that uses a magnet linked to a computer to create pictures of an area inside the body.
- Mammogram: An X-ray of the breast, taken with a device that compresses and flattens the breast. Recommended for older women and those with a family history of breast cancer.
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