Abstract
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Radiologists in the field of breast cancer screening and diagnosis who interact with women daily know that, in fact, breast cancer screening is a complex and emotionally charged issue. There are many misperceptions about personal risk, imaging options, realistic expectations about efficacy, and appropriate choices for utilization. Moreover, there are wide variations in the skill levels of imagers interpreting the results at different facilities. 1
Most women do not have a clear understanding of the guidelines and recommendations regarding timing for baseline screening, frequency of screening, and choices about technologies available. This is, in part, a consequence of the lack of consensus among professional and government-supported organizations and associated messaging. The information is complex even for primary care physicians (PCPs) who are trained to interpret studies and data. It becomes almost incomprehensible for women given the conflicting information presented in the popular press and via social media.
Like many others across the country, our breast imaging centers have sought to educate women about screening recommendations, new legislation, breast density issues, risk factors, and new technologies. We have done this via mailings, reminders, YouTube videos, website postings, and evening educational programs. Despite our best efforts, patient focus groups inform us that we are not effectively educating the public. Clearly, we need better ways to reach women.
Many women may not understand what their PCPs have told them about screening; moreover, overburdened primary care physicians are often unaware of advancements in techniques and technology and are thus ill equipped to participate with the patient in informed decision making. Theoretically, shifting the burden from the PCP to the breast imaging center would lead to more enlightened patient-provider discussions and better value for both the patient and the health system.
Currently, women who may be uninformed or have inaccurate or incomplete information are asking to drive their own care. For instance, many women experience such extreme anxiety that when offered a 6-month follow-up diagnostic test, they opt instead to have a breast biopsy performed. This may lead to poor quality patient care and may add to the cost of breast cancer screening and diagnosis. There is no question that appropriate and well-directed education of PCPs and women will assist in promoting more effective utilization and greater value for breast cancer screening and detection. However, as noted above, the best means for accomplishing this are elusive. Nonetheless, we must continue to explore new approaches with the benefit of patient feedback.
On the bright side, advances in technology are beginning to change the equation: tomosynthesis (3-dimensional mammography), a U.S. Food and Drug Administration-approved breast cancer imaging technology, vastly improves the radiologist's ability to distinguish between inconsequential findings and potential cancers. The result is that there are fewer false positive recalls from screening exams, less need for additional imaging studies, and fewer unnecessary biopsies. A major benefit for women is a reduction in anxiety caused by the uncertainty and stress of additional diagnostic tests that may result in normal findings. Ultimately, lessening the need for recalls will reduce the financial burden for both the individual patient and the health care system.
Another important concept for education and deployment in clinical practice is tailored screening for women based on risk factors. Tailored screening will utilize more accurate algorithms that increase cancer detection and add value to screening for, and diagnosis of, breast cancer. This will provide higher quality at lower cost, resulting in greater value.
Today, risk is assessed by relatively crude methods including genetic testing that impacts a small percentage of women, breast tissue density that is mainly a subjective assessment, and risk estimates after high-risk lesions are found at biopsy. While these are the best tools available currently, many other promising tests are in the pipeline. These include developing technologies such as blood tests, assessment of blood flow and metabolic markers in the breast, and new genetic markers. The goal is to assess pretest probability of breast cancer to direct the frequency and extent of screening needed for each individual woman. These tools will be important as we address the rising pressures of providing excellent care with limited resources and at low cost.
Health care is entering a new economic era wherein payments to health care providers and out-of-pocket costs to patients will take into account both quality and cost—the so-called value equation. This will require patients to be better informed and actively involved in their health and the services they receive. At the same time, it will demand more accountability from providers in terms of quality outcomes and cost (e.g., Accountable Care Organizations). This will change and challenge traditional relationships and utilization of screening and diagnostic services that are limited resources. For example, Maryland has become the first of many states to permit population-based payments for care of patients. This will likely extend to individual institutions using similar strategies to screen, diagnose, and treat breast cancer for a predetermined set fee. Thoughtful planning will be essential in developing programs focused on early detection and treatment to keep costs down and the quality of care high.
The articles in this supplement are timely and reveal surprisingly complex issues. They speak to the costs and benefits of screening for women, the substantial psychological impact of the disease and screening processes for some women, the unresolved questions of how to better educate women and their providers, and the direct and “hidden” cost burden of inconclusive screenings/recalls for women and multiple stakeholders across the spectrum of care.
Collectively, they illustrate the need for a more tailored approach to breast cancer awareness, education, and screening. The goal is to make appropriate screening and diagnosis easier on women and more responsive to the changing face of value-based health care.