New Breast Cancer Screening Recommendations: Sound Advice?
The U.S. Preventive Services Task Force (USPSTF) released on April 20 draft recommendations for breast cancer screening. Although imaging technology has advanced quite a bit since the release of their 2009 recommendations, the independent, volunteer panel of national healthcare experts is skeptical and cautionary.
The pending 2015 breast cancer screening recommendations continue to support screening mammography every 2 years for women ages 50 to 74 years, and for women 40 to 49 years if the situation merits it. The benefits of screening mammography for women 75 years and older remain inconclusive, according to the USPSTF.
Noticeable differences are the absence of any mention regarding self or clinical breast exams; and the consideration of new technology, such as breast ultrasound and 3D digital mammography. Newer techniques for breast cancer detection have become widely popular among the healthcare community, but the USPSTF and payers aren’t convinced they should be used for screening purposes.
The USPSTF, in its draft 2015 recommendations, concludes, “The current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasound, magnetic resonance imaging (MRI), tomosynthesis, or other modalities in women identified to have dense breasts on an otherwise negative screening mammogram.”
In a decision memo for breast biopsy (CAG-00040N), the Centers for Medicare & Medicaid Services says, “Ultrasound is generally not an effective tool for routine breast cancer screening because sonographic imaging fails to detect microcalcifications. The main usefulness of ultrasound appears to be enhanced ability to distinguish between solid and cystic masses.”
The American College of Obstetricians and Gynecologists also does not recommend routine use of alternative or adjunctive tests to screening mammography in women with dense breasts who are asymptomatic and have no additional risk factors.
Legislation for Reporting Density Causes Confusion
Physicians in states that have adopted breast density reporting are required to notify women who have undergone mammography and were found to have dense breast tissue, which can make it more difficult to detect breast cancer. Breast density reporting regulations have been put into effect in 22 states, and several other states are in the progress of adopting the regulations.
The lack of coverage by payers, however, may confuse patients who are requesting a screening ultrasound based on what they may believe is a recommendation for the service from their breast imaging center.
Experts warn of the delicate nature of notifying women who have been identified to having dense breasts.
“The manner in which the information is shared is important,” Richard Frank, MD, PhD, chief medical officer for Siemens Healthcare North America and founding member of the Quantitative Imaging Biomarkers Alliance of the Radiological Society of North America, told Diagnostic Imaging. “There might be value in not just sending a letter through the mail, but giving it to her. She then has an opportunity to actually talk about it.”
Providers should educate patients on the benefits verses harms of these adjunctive screening modalities so informed decisions can be made based on facts and not fear.
2015 Coding Somewhat Misleading
It’s important to note that neither Medicare nor the USPSTF has approved the use of ultrasound to screen for breast cancer, so the two new codes for ultrasound of the breast, 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete and 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited may not be used for that purpose.
These codes are intended for diagnostic ultrasound only. For example, in the event the provider determines a patient has dense breast tissue, he or she may advise the patient to consider a diagnostic ultrasound. The 2D mammography would be considered a preventive screening, with no co-pay or deductible. The diagnostic ultrasound, however, would be subject to patient cost-sharing.
Alternatively, 3D mammography (tomosynthesis) is covered under Medicare. Per MM8874 revised:
In the CY 2015 PFS Final Rule with comment period, CMS established a payment rate for the newly created CPT code 77063 [Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)] for screening digital breast tomosynthesis mammography. The same policies that are applicable to other screening mammography codes are applicable to CPT code 77063. In addition, since this is an add-on code it should only be paid when furnished in conjunction with a 2D digital mammography [HCPCS Level II code G0202 Screening mammography, producing direct digital image, bilateral, all views, 2D imaging only].
Public comment on the USPSTF draft 2015 recommendations for breast cancer screening ends May 18.