Jean M. Weigert, MD, FACR
In 2009, Connecticut became the first state to enact legislation mandating that patients undergoing mammography be informed of their breast density and the option to have a follow-up ultrasound.
Breast density reporting laws are now in effect in 22 states, and bills were introduced in several others this year. At the federal level, the Breast Density and Mammography Reporting Act of 2015 is pending in the House of Representatives and the Senate (HR 716/S 370).
To assess the impact of additional screening, Jean M. Weigert, MD, FACR, head of breast imaging for the Hospital of Central Connecticut, conducted a retrospective chart review to see how well it worked in detecting cancers in women with dense breasts during the first 4 years of implementation statewide.
Her study, reported at the 2014 San Antonio Breast Cancer Symposium, found that this supplemental ultrasound screening of dense breasts did detect a significant number of breast cancers not discovered by a mammogram.1 OncLive
sat down with Weigert to discuss her research and learn more about how breast density reporting is working in practice.Q: What was the impetus for your study?
Back in 2009, then Connecticut Governor Jodi Rell, a breast cancer survivor herself, signed a law mandating that patients be informed of their breast density—whether it was less than or greater than 50%. As part of that mandate, clinicians were to explain that if women had breast tissue density greater than 50%, they might want to talk to their doctors about supplemental imaging with breast ultrasound; 2 years later, breast MRI was included as an adjunct as well.
This legislation was the first in the nation, and it was groundbreaking because AreYouDense.org, a grassroots group of breast cancer survivors, really pushed to have this done. In 2007, I testified before the state legislature as a delegate from our state radiology society against this legislation because we didn’t feel that there were enough data to support it.
But when the ACRIN [American College of Radiology Imaging Network] 6666 study2
documented that they could find an additional 4.2 per thousand cancers in women who had high risk, it certainly became untenable for us to not go ahead and say OK, now there are data, and I thought this presented a great opportunity for a small state to gather more.
Working with a medical student from the University of Connecticut, in the first year we collected data from 12 sites around the state, and the data were published in Breast Journal in 2012.3
We then gathered the data for the second year and observed similar findings—approximately over three additional breast cancers per thousand, which basically doubles the number of breast cancers that we find on just screening mammogram alone. I also was still collecting this data in my practices and decided to continue to do this for a few more years because 1 or 2 years really doesn’t provide enough information.
We didn’t know whether the numbers would fall off, whether people would even come, and what kind of cancers we would find. There was still a great deal of skepticism around the country, but at the same time, more of these breast density reporting bills were being signed. This was a unique opportunity.
I pulled out the data from my five offices for the years 1 through 4. I tallied it all up, compared it, and found—much to my surprise—we continued to find 3.2 additional cancers per thousand cancers in this cohort of patients with breast tissue density greater than 50%.Q: What did your study find with respect to women with dense breasts actually getting the follow-up ultrasound screening?
Over the 4 years, we were still only getting about 30% of women coming in who were eligible because of their breast density, despite the fact that Connecticut is one of just a few states where insurance covers this with just a code of “dense breast tissue.” Still, there are certainly a lot of high-deductible plans, so women are being cautious. They may not come back for this if they have a high deductible and do not want to pay for the ultrasound (average cost about $100). As we get more education out, and now with 4 years of data, I think that is enough to show that this is a worthwhile study.Q: Is there an issue with false positives?