By Andrew Kitchenman - www.njspotlight.com

Radiologists, obstetricians split on need for follow-up screening if mammograms reveal high-density breast tissue

Should women in New Jersey whose mammograms reveal that they have extremely dense breast tissue follow up with an ultrasound -- and should insurers be required to pick up the tab for the additional test?

Those questions -- at the heart of a bill being considered by the Assembly -- are causing contention among medical specialists and lawmakers.

The measure (A-2022/S-792) also requires a statement to accompany dense-tissue mammograms advising women to ask their doctors if further testing is indicated.

While radiologists support the bill, saying it will help women become better educated about breast density, it’s opposed by obstetricians. The latter contend that it will lead to unnecessary tests to head off lawsuits.

The bill was released by the Assembly Health and Senior Services Committee on March 7. The Democrats on the committee voted in favor; the committee's four Republicans abstained. The Senate passed its version of the bill in June.

Based on a Connecticut law that has led to an increase in breast ultrasounds in that state, the legislation is being opposed by the New Jersey section of the American Congress of Obstetricians and Gynecologists, or ACOG. Participating doctors are worried that physicians will reflexively order ultrasounds for all women with extremely dense breast tissue to prevent lawsuits, when there is no medical consensus that the tests are appropriate.

Some of the sharpest questioning of the bill came from Assemblyman Herb Conaway Jr. (D-Burlington), the committee chairman. Although he ultimately voted to release the bill, Conaway argued that it intrudes on the doctor-patient relationship by stipulating information that physicians must convey to patients.

“That is unprecedented -- I will tell you that,” said Conaway, a doctor who practices internal medicine. “And I haven’t spoken to a physician yet who has said the government should tell us what to say to patients.”

Assemblyman Troy Singleton (D-Burlington) said he decided to sponsor the bill after hearing from constituents who were diagnosed with breast cancer and had wished they had known earlier that dense breast tissue may indicate an elevated risk of developing breast cancer.

Singleton described one woman's position: “It’s not going to save her life, it’s not going to prolong her life, but what it will do is perhaps help some others and put them in a better position” to detect cancer early.

Breasts are considered dense when more of their tissue is composed of glands than of fat. While dense breast tissue doesn’t cause cancer, it makes it more difficult to detect cancer in mammograms.

According to Dr. Lisa Weinstock, a bill supporter who owns Ridgewood breast imaging center Women’s Digital Imaging, a combination of mammograms and ultrasounds can detect cancer earlier.

“It’s like a blind spot on the mammogram,” Weinstock said of cancer tissue. While cancer and glandular tissue are a similar color in mammograms, they are different colors in ultrasounds.

Singleton cited a Connecticut study that found 28 cases of cancer were detected early by six medical practices as a result of that state’s law.

Dr. Sharon Mass, state ACOG chairwoman, said ob/gyns and other primary-care doctors currently follow the advice of radiologists in deciding whether to order ultrasounds. She said the bill would increase pressure on doctors to order ultrasounds, even though it hasn’t been proven that the tests benefit patients with dense breasts.

Mass noted that there are several downsides to ultrasounds, including a higher percentage of false-positives than mammograms. In addition, they lead doctors to order more biopsies.

“I know that when my patients are told that they need a biopsy, they are absolutely terrified,” said Mass, a breast cancer survivor who has undergone radiation therapy as well as six cycles of chemotherapy.

She also raised a concern about the cost-effectiveness of the ultrasounds, noting that the average number of ultrasound breast screenings at Yale New Haven Hospital rose from 1 per day to 40 per day, at a cost of roughly $350 to $500 per screening.

Dr. Roger Yang, vice president of the New Jersey Radiologic Society, said he saw the benefits of the bill as being primarily educational. He also said there would be a benefit to requiring insurers to cover screening ultrasounds rather than the less-sensitive diagnostic ultrasounds that are sometimes used today.

The educational value of the measure also was emphasized by cosponsor Assemblyman Daniel R. Benson (D-Mercer and Middlesex), who said patients may not be aware of the potential problems resulting from having dense breasts.

Conaway, however, questioned what message patients are receiving when there is no national medical consensus about the benefits of additional screening tests after mammograms indicate dense breasts.

“We send that information out. What does the patient do with it?” Conaway asked.

Republican committee members expressed skepticism about the bill, saying the state shouldn’t mandate coverage for a test that isn’t required by any national group. Weinstock said passing the measure would advance an effort to create a national standard.

The next step for the bill would be a vote by the entire Assembly, which hasn’t been scheduled.

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