Despite Katie Couric’s advice, doctors say ultrasound may not be a breast exam

When Katie Couric shared the news of her breast cancer diagnosis, the former co-host of NBC’s “Today” show said she viewed this new health challenge as a teachable moment to encourage people to get needed cancer screenings.

“Please get your annual mammogram,” she wrote on her website in September. “But just as important, please find out if you need additional screening.”

In the article, Couric, 65, explained that because her breast tissue tends to be dense, she gets an ultrasound exam in addition to a mammogram when screening for breast cancer. A breast ultrasound, sometimes called a sonogram, uses sound waves to take pictures of breast tissue. It can sometimes detect malignancies that are difficult to detect on mammograms in women who have dense breasts—ie, a high ratio of fibrous tissue and glandular versus fatty tissue.

Couric, who famously performed a colonoscopy on live television after her first husband died of colon cancer and lost her sister to pancreatic cancer, has long pushed for cancer screening and better detection options.

Breast cancer experts applauded Couric for drawing attention to breast density as a cancer risk factor. But some were less comfortable with his support for supplemental screening.

“We don’t have evidence that supportive screening reduces breast cancer mortality or improves quality of life,” said Dr. Carol Mangione, a professor of medicine and public health at UCLA who chairs the US Preventive Services Task Force, a group of medical experts working to measure their benefits and harms. Later makes recommendations for preventive services.

Couric’s office did not respond to requests for comment.

In addition to an annual mammogram, some women with dense breasts get a breast ultrasound or MRI to help detect cancerous cells missed by a mammogram. Dense fibrous tissue appears white on a mammogram and makes it difficult to see cancer, which also appears white. Fatty breast tissue, which appears dark on a mammogram, does not obscure breast malignancy.

As digital breast tomosynthesis, or 3D mammography, has become more widely available, an increasing number of women are receiving that screening test instead of standard 2D mammography. 3D mammography has been found to reduce the number of false positives and detect more cancers in some women with dense breasts, although the effect on mortality is unknown.

The task force gives an “I” rating to supplemental screening for women with dense breasts whose mammogram results do not indicate a problem. That means the current evidence is “insufficient” to assess whether the benefits of additional screening outweigh the harms. (The task force is updating its recommendations for breast cancer screening, including supplemental screening for women with dense breasts.)

In addition to potential additional costs, a key pitfall that researchers worry about is the possibility of a false-positive result. Complementary imaging in women who are not at high risk for breast cancer can identify potential problem spots, making follow-up testing such as breast biopsy invasive and raising cancer fears for many patients. But studies have shown that often these results turn out to be false alarms.

If 1,000 women with dense breasts got an ultrasound after a negative mammogram, the ultrasound would detect two to three cancers, research shows. But additional imaging will identify 117 potential problems that lead to recalls and tests but are ultimately determined to be false positives.

“On the one hand, we want to do everything we can to improve detection,” said Dr. Sharon Maas, an OB-GYN in Morristown, New Jersey, and former chair of the American College of Obstetricians and Gynecologists’ New Jersey Section. “But on the other hand, there is enormous cost and emotional distress associated with false-positive results”.

The professional group does not recommend supplemental screening for women with dense breasts who have no additional risk factors for cancer.

Many other professional groups take the same position.

“We recommend having a conversation with a health care provider and asking patients to understand if their breasts are dense,” Maas said. “But we don’t recommend testing everyone.”

In particular, for the roughly 8% of women who have extremely dense breasts, it’s worth having a conversation with a doctor about additional screening, Mass said.

Similarly, for women with dense breasts who have additional risk factors for breast cancer, such as a family history of the disease or a personal history of breast biopsy to check for suspected cancer, supplemental screening may make sense, she said.

Dense breasts are relatively common. In the United States, approximately 43% of women age 40 and older have breasts that are considered dense or very dense. In addition to making mammograms difficult to interpret, women with dense breasts are twice as likely to develop breast cancer as women with breasts of average density, research shows.

Studies have shown that mammograms reduce breast cancer mortality. But while it seems intuitive that more tests would improve someone’s chances of missing cancer, studies have not shown that women who get a supplemental ultrasound or MRI after a negative mammogram result are less likely to die of breast cancer.

Some studies have shown that those with dense or very dense breasts who underwent an ultrasound or MRI in addition to a mammogram had fewer so-called interval cancers between routine screening mammograms. But it’s unclear whether these findings have any effect on the risk of dying from breast cancer.

“Not every little abnormality is going to lead to something that needs treatment,” says Mangione.

Thirty-eight states and the District of Columbia have laws requiring patients to be informed of breast density after a mammogram, although some require only a general notice to inform individual women of their own status. Some states require insurers to cover supplemental testing, but others do not.

In 2019, the FDA proposed that information about breast density be included in the letters patients receive after a mammogram. That rule has not yet been finalized, but the agency has told lawmakers it expects to issue the rule early next year.

In a statement to KHN, FDA spokeswoman Carly Kempler said, “FDA is committed to improving mammography services for patients and working diligently to finalize the rule revising existing mammography regulations.”

Another factor to consider is the cost of additional testing. Because the Preventive Services Task Force recommends women get regular screening mammograms, health plans in general are required to cover them without charging people anything out-of-pocket. This is not the case for supplemental screening for women with dense breasts, which the task force does not recommend. Some states require insurance coverage for those tests, but those laws do not apply to many plans in which employers “self-fund” employee benefits instead of purchasing state-regulated insurance coverage.

Complementary imaging can be expensive if your health plan doesn’t cover it. According to the Bram Foundation to Defeat Breast Cancer, a screening ultrasound can cost $250 while a breast MRI can cost $1,084.

Rep. Rosa DeLauro (D-Conn.) recently tweeted that she Working on a bill With Couric that will cover MRIs and ultrasounds for women with dense breasts at no out-of-pocket cost.

Some doctors recommend other measures more effective than additional screening for women with dense breasts who want to reduce their risk of breast cancer.

“If you really want to help yourself, lose weight,” says Dr. Karla Kerlikoske, a professor of medicine and epidemiology/biostatistics at the University of California-San Francisco, who has worked with other researchers to develop calculators that help providers evaluate patients for breast cancer. the risk “Moderate your alcohol intake and avoid long-term hormone replacement. These are things you can control.”

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