Breast Cancer and Hormone Replacement Therapy (HRT)

Perhaps the most significant worry that most women have when considering whether or not to take Hormone Replacement Therapy (HRT) is the possible increased risk of breast cancer. Breast cancer is an estrogen dependent cancer and constitutes approximately 25% of all female cancers, therefore any woman who has an early menopause and does not take any estrogen supplementation will actually reduce her risk of developing breast cancer in later life.

There are two main types of HRT:

  • combination HRT contains the hormones estrogen and progesterone
  • estrogen-only HRT contains only estrogen

Combination HRT increases breast cancer risk by about 75%, even when used for only a short time. Combination HRT also increases the likelihood that the cancer may be found at a more advanced stage, as well as increasing the risk that a woman diagnosed with breast cancer will die from the disease. Breast cancer risk increases the most during the first 2 to 3 years of taking combination HRT. Higher-dose combination HRT increases breast cancer risk more than lower-dose combination HRT. Breast cancer risk goes back down to average about 2 years after you stop taking combination HRT.

Estrogen-only HRT increases the risk of breast cancer, but only when used for more than 10 years. Estrogen-only HRT also can increase the risk of ovarian cancer.

If you’ve been diagnosed with breast cancer or have tested positive for an abnormal breast cancer gene (BRCA1 or BRCA2) and so are at high risk, you shouldn’t use HRT. The hormones in HRT can cause hormone-receptor-positive breast cancers to develop and grow. While only a few small studies have looked at HRT use in women with a personal history of breast cancer, the fact that HRT use increases breast cancer risk among women in general makes almost all doctors advise women with a personal history of breast cancer to avoid HRT. The prescribing sheet included with HRT clearly states that it is “contraindicated in women with a diagnosis of breast cancer.”

Menopausal side effects can dramatically reduce quality of life for some women. These women have to weigh the benefits of HRT against the risks.  If you’re having severe hot flashes or other menopausal side effects and have a personal history of breast cancer, talk to your doctor about non-hormonal options, such as dietary changes, exercise, weight management, acupuncture, or meditation.

The small increase in the incidence of breast cancer in long-term users of HRT should be considered in the context of the benefits of HRT. Long-term use is indicated for the prevention of serious disorders as osteoporosis and cardiovascular disease (and perhaps also useful in the prevention of dementia). Only in women without any risk factor for these diseases and especially for cardiovascular disease, the excess of breast cancer is of real importance in terms of cost-benefit calculations. But for some women a small increase in the incidence of breast cancer is so terrifying, that they accept the probability of an earlier (premature) cardiovascular death.

Whether or not you take HRT, there are also lifestyle choices you can make to keep your breast cancer risk as low as it can be:

  • maintaining a healthy weight
  • exercising regularly
  • limiting alcohol
  • eating nutritious food
  • never smoking (or quitting if you do smoke)

These are just a few of the steps you can take to reduce your risk of breast cancer.

Bottom line: If you’ve been diagnosed with breast cancer or have tested positive for an abnormal breast cancer gene (BRCA1 or BRCA2) and so are at high risk, you shouldn’t use HRT.  Patients with menopausal symptoms should speak to their doctor about treatment options.

(*information for this article was obtained from breastcancer.org)

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA.


Osteoporosis Affects Women AND Men

Osteoporosis is disease of the bones that occurs when a person loses too much bone, produces too little bone or both and can affect both men and women. Osteoporosis is often called the ‘silent thief’ because bone loss occurs without symptoms unless one has fractured. The disease can result in disfigurement, lowered self-esteem, reduction or loss of mobility, and decreased independence.

But while millions of men suffer from osteoporosis, the vast majority of people with this potentially painful condition are women. The International Osteoporosis Foundation estimates that osteoporosis affects about 200 million women worldwide.

Fractures from osteoporosis are more common than heart attack, stroke and breast cancer combined. At least 1 in 3 women and 1 in 5 men will suffer from an osteoporotic fracture during their lifetime. Why the gender gap? Women start with lower bone density than their male peers and they lose bone mass more quickly as they age, which leads to osteoporosis in some women. Between the ages of 20 and 80, the average white woman loses one-third of her hip bone density, compared to a bone density loss of only one-fourth in men.

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, osteoporosis statistics show a greater burden for women in the following ways:

  • 68 percent of the 44 million people at risk for osteoporosis are women.
  • One of every two women over age 50 will likely have an osteoporosis-related fracture in their lifetime. That’s twice the rate of fractures in men — one in four.
  • 75 percent of all cases of hip osteoporosis affect women.

Osteoporosis and Estrogen

Estrogen is a hormone that helps regulate a woman’s reproductive cycle. At the same time, it plays a role in keeping bones strong and healthy, in both men and women. While premenopausal women have more estrogen than men, they will experience dramatic drops in estrogen production due to menopause, and are more likely to experience bone loss and osteoporosis at that time.

Women are at increased osteoporosis risk related to estrogen levels if they:

  • Experience irregular or infrequent periods, or began having their periods at a later than normal age.
  • Have had their ovaries removed (at any age).
  • Are going through menopause, with those undergoing menopause at an early age having an even higher risk.

 

Women lose bone mass much more quickly in the years immediately after menopause than they do at any other time in their lives.

In contrast, data suggests that women who have more estrogen than their peers, such as women who began their menstrual cycles earlier than normal or who have used estrogen containing contraceptives, are likely to have higher bone density.

Osteoporosis: Underdiagnosed in Men

Because osteoporosis occurs more frequently in women than men, less attention is paid to bone health in men, and those who have osteoporosis may go undiagnosed and untreated. A study of 895 nursing home residents over age 50 revealed that doctors were less likely to consider osteoporosis diagnosis and treatment for men than women, even when the men had recently experienced a fracture, a widely recognized red flag for osteoporosis. The reality is that 80,000 men experience osteoporosis-related fractures every year, and close to 23,000 die as a result of fracture-related complications.

Bone loss is a normal part of aging in both men and women; by about age 75, men and women lose bone at the same rate and both genders are less able to absorb calcium. However, when men get osteoporosis, it is usually related to another health condition, a lifestyle choice (smoking or alcohol abuse), or medication that has bone loss as a side effect.

Bottom line: Osteoporosis risk is different for men and women, but the disease is dangerous for anyone who gets it. Talk to your doctor about getting an osteoporosis screening if you know you have risk factors.

 

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA.


Men Can Get Breast Cancer

Breast cancer in men is a rare disease. Less than 1% of all breast cancers occur in men. In 2016, about 2,600 men are expected to be diagnosed with the disease. For men, the lifetime risk of being diagnosed with breast cancer is about 1 in 1,000.

Wait, men don’t have breasts like women, so how do they get breast cancer? The “breasts” of an adult man are similar to the breasts of a girl before puberty. In girls, this tissue grows and develops, but in men, it doesn’t. But because it is still breast tissue, men can get breast cancer. Men get the same types of breast cancers that women do, but cancers involving the parts that make and store milk are rare.

Who Is at Risk?

Most breast cancers happen to men between ages 60 and 70. Other risk factors of male breast cancer include:

  • Breast cancer in a close female relative.
  • Previous radiation treatment to the chest increases your risk.
  • History of radiation exposure of the chest.
  • Enlargement of breasts (called gynecomastia) from drug or hormone treatments, or even some infections and poisons.
  • Taking estrogen.
  • A rare genetic condition called Klinefelter’s syndrome.
  • Severe liver disease (called cirrhosis).
  • Diseases of the testicles such as mumpsorchitis, a testicular injury, or an undescended testicle.

What Are The Symptoms of Breast Cancer in Men?

The symptoms of breast cancer in men are similar to those in women. These include:

  • A breast lump that you can see or feel
  • An enlargement of one breast
  • Nipple pain
  • Discharge from the nipple
  • Sores on the nipple or areola
  • An inverted nipple
  • Enlarged underarm lymph nodes

 

The good news is that treatment and survival rates are largely the same for men as for women. The five-year relative survival rate for male breast cancer is 84 percent. The 10-year relative survival rate is 72 percent. These are only averages, though. Breast cancer also tends to be diagnosed later in men than in women.

Where the difference lies is in diagnosis and screening. As Marleen Meyers, an assistant professor of medical oncology with NYU Langone Medical Center told U.S. News and World Report last year, men don’t undergo routine breast cancer screenings.  “They only seek medical attention when they feel a lump, whereas women have routine screenings and get it identified earlier,” Meyers said. “By the time men come in, the tumor is usually at least 1 centimeter in size, and the cancer has often spread.”

Because male breast cancer is so rare, experts don’t see much benefit in general-population screenings, such as mammograms, according to the American Cancer Society.

As always, if you experience any of the symptoms associated with breast cancer, see your doctor right away and get evaluated. Regardless whether you are a man or woman, the best way to fight breast cancer is through awareness and early detection.

Bottom line: Less than 1% of breast cancer occurs in men, but men can and do get breast cancer. Although men do not require yearly screening mammograms, awareness of the signs and symptoms can lead to early detection and improved survival.

 

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA.


Mammography Helps Detect Heart Risk in Women!

Widely used mammography screening for breast cancer could potentially serve as a tool for detecting heart risk in women as well, a new study suggests.

Researchers said the study, involving 292 women, showed a strong correlation between the amount of calcium detected in breast arteries on a mammogram and the level of calcium in coronary arteries. Calcium in the arteries that nourish the heart is an important predictor of risk for heart attacks and strokes.

The findings of the study were presented at the American College of Cardiology’s 65th Annual Scientific Session and published March 24 in the journal Cardiovascular Imaging.

The new study identifies “an accessible way with no extra cost and no extra radiation [exposure] of determining someone’s risk for cardiovascular disease,” said Laurie Margolies, chief of breast imaging at Mount Sinai Medical Center, New York and lead author of the study.

Breast-artery calcium was at least as strong at predicting calcium in the coronary arteries as more traditional measures such as blood pressure, cholesterol and the widely used Framingham Risk Score, the study showed. “We hope this could be practice-changing,” Dr. Margolies said.

Some 37 million mammography exams are done in the U.S. each year, and often detect what doctors call “calcifications”—tiny spots of calcium that are generally benign, but can sometimes indicate breast cancer.

Mammography also picks up calcium in the breast arteries, which cardiologists have long considered potentially useful in assessing a woman’s heart risk.

While breast cancer takes the lives of approximately 40,450 women in the U.S. each year, according to the American Cancer Society, it’s not the top killer of women. Most women, it turns out, should be much more fearful of heart disease, since heart attack and stroke take the lives of more than 292,000 American women annually.

This new study showed that women with a high breast-artery calcium score—between four and 12—were more than three times as likely to have calcium in their coronary arteries as women who scored zero on the mammogram.

If such information were routinely included in a mammogram report, it could lead women to undergo further tests, including blood tests or heart scans to evaluate their heart risk. That could prompt such preventive strategies as changes in diet and exercise or use of cholesterol-lowering drugs called statins to reduce heart risk, Dr. Margolies said.

It is estimated that if 10% of women undergoing mammography tested positive for breast-artery calcium, nearly three million would turn out to have early signs of heart disease.

Bottom line: Mammography is now proven to have the additional benefit of screening for cardiovascular disease in women, without additional radiation or risk.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA.


Dense Breasts: Ultrasound Beats 3D Mammography!

Ultrasound turned in a better incremental breast cancer detection rate than tomosynthesis in mammography-negative dense breasts, and a similar false-positive rate, according to interim findings from the ASTOUND trial.

During 2012-2015, the multicenter Adjunct Screening With Tomosynthesis or Ultrasound in Women With Mammography-Negative Dense Breasts (ASTOUND) trail screened 3,231 dense-breasted asymptomatic women (median age 51) with negative mammograms using both tomosynthesis and physician-performed ultrasonography.

Among more than 3,000 mammography-negative screening participants with dense breasts, 24 additional breast cancers (BC) were detected, of which 23 were invasive. All 23 were detected with ultrasound for an incremental cancer detection rate (CDR) of 7.1 per 1,000 screens (95% CI 4.2-10.0, P=0.006) versus 13 found with tomosynthesis (incremental CDR 4.0 per 1,000 screens, 95% CI 1.8-6.2), reported Nehmat Houssami, MBBS, MPH, PhD, of the University of Sydney, and colleagues. This study was recently published in the Journal of Clinical Oncology and presented at the 1oth European Breast Cancer Conference.

“Our results could be taken to suggest that tomosynthesis is detecting [breast cancers] that would have been otherwise masked (on 2D mammography) by overlapping breast parenchyma, but seems less capable than ultrasound at finding cancers that are entirely masked by mammography-dense tissue,” Houssami’s group wrote. “We assume that some cancers are visible to only one of the physical principles of imaging modalities (x-ray for tomosynthesis vs ultrasound).”

The majority of ultrasound-detected cancers undetected by tomosynthesis were masses, whereas the single malignancy detected by tomosynthesis but missed by ultrasound was an architectural distortion.

The authors pointed out that these results are interim only, and relate to a self-referring population of women with dense breasts and negative mammograms.

One of the historical barriers to implementing ultrasound (US) breast cancer screening in practice has been the high rate of false-positives, explained Wendie Berg, MD, PhD, of Magee-Womens Hospital of University of Pittsburgh Medical Center, in an accompanying editorial.

“Importantly, in preliminary results from the ASTOUND trial, false-positive recalls (2.0%) and biopsies (0.7%) were acceptably low,” she noted.

However, she pointed out that “these low rates likely reflect that most of the US screens in ASTOUND were incident screens (with prior examinations available); further, recommendations for short interval follow up (Breast Imaging-Reporting and Data System density categories three) were not considered test positive.”

But Berg suggested that the two modalities can work together. “On the basis of the results from ASTOUND, tomosynthesis still misses a substantial number of invasive cancers in women with dense breasts: supplemental US after tomosynthesis would still be reasonable, although further study is warranted,” she wrote.

Bottom line: The combination of 3D tomosynthesis mammography and whole breast ultrasound significantly improves breast cancer detection in women with “dense” breasts.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA.


Breast Cancer Detection: Ultrasound EQUAL to Mammography!

Breast cancer is one of the most prolific type of ailment that has plagued women for many years. In order to fight the disease, experts agree that focusing more on ultrasound can help detect and fight the illness while still in its early stage.

In a study published by the Journal of the National Cancer Institute, researchers concluded that ultrasound and mammography appear equally likely to detect breast cancer. Breast cancer cases are increasing worldwide; more than 1.6 million new cases of the disease were diagnosed in 2010, resulting in more than 425,000 deaths. Furthermore, an estimated 2.1 million new diagnoses of breast cancer are expected by 2030. Mammography is proven effective in detecting breast cancer in developed countries; however, it is not commonly available in less developed nations, and alternative methods, such as ultrasound, need to be investigated.

Researchers at Magee-Womens Hospital, in Pittsburgh, Pennsylvania, recruited 2809 women across 20 sites in the United States, Canada, and Argentina to the American College of Radiology Imaging Network protocol 6666 breast cancer screening study. The objective was to determine the effectiveness of ultrasound in detecting breast cancer.

Of the participants, 2662 completed 3 annual breast screenings by US and film-screen or digital mammography, then underwent a biopsy or a 12-month follow-up.

Study results show the number of ultrasound screens needed to detect breast cancer was comparable to that of mammography, and found that a greater proportion of invasive and node-negative cancers were found in those who underwent ultrasound. However, they also saw a greater number of false-positives among the women screened with ultrasound. Although the false-positive rate is higher with ultrasound than with mammography, the number of women recalled for extra testing becomes more comparable on incidence screening rounds.

Overall, the researchers found that 32 percent of more than 2,500 women without cancer were asked to come back for additional testing at least once after an ultrasound. That compared to 23 percent of women who’d had mammography, the study said.

The findings suggest that for women who don’t have a high risk of breast cancer but have dense breasts, “we find many more cancers if we do ultrasound in addition to mammography,” study leader Dr. Wendie Berg, professor of radiology at Magee-Womens Hospital of UPMC in Pittsburgh. Berg said the cost of mammography and ultrasound are comparable in the United States. “The issue is: what are the cancers we most need to find,” she said. “The cancers you need to find are the invasive, node-negative ones. More of the cancers found with ultrasound were invasive and node-negative than those found with mammography.”

“Where mammography is available, ultrasound should be seen as a supplemental test for women with dense breasts who do not meet high-risk criteria for screening MRI and for high-risk women with dense breasts who are unable to tolerate MRI,” stated the authors. The study was published Dec. 28 in the Journal of the National Cancer Institute.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA.


Screening Mammogram PLUS Ultrasound IMPROVES Breast Cancer Detection!

The addition of ultrasonography to mammography significantly improves the rate of detection of breast cancers in Japanese women, according to trial findings published online in The Lancet on November 5th.

Findings showed that combining ultrasound with mammography resulted in correctly detecting cancer in more than 9 of 10 cases (91% sensitivity), whereas for women given mammography alone, just more than three quarters of tests correctly identified breast cancer (77% sensitivity).

These data are important because mammography screening alone may not be sufficient for screening Asian women, owing to the fact that they characteristically have higher-density breasts than women of other ethnicities and because breast cancer tends to present at an earlier age in Japan than in Europe or the United States. The accuracy of mammography is reduced both in women with high-density breast tissue and in young women.

Therefore, the use of adjunctive ultrasonography could offer a low-cost way to increase sensitivity and detection rates of early cancers in women with dense breast tissue, note the authors, led by Noriaki Ohuchi, MD, PhD, of Tohoku University Graduate School of Medicine, Miyagi, Japan.

“Our results suggest that adding ultrasound to mammography results in more accurate screening results for women in Japan, which could ultimately lead to improved treatment and reduced deaths from the disease,” said Dr Ohuchi in a statement. “Further work will now be needed to see if these results can be extended to other countries in Asia. In addition, long-term follow-up of these results will determine whether including ultrasound tests in breast cancer screening ultimately affects the likelihood of successful treatment and survival, as we would expect.”

Higher Detection of Invasive Cancers

In the Japan Strategic Anti-cancer Randomized Trial (J-START), Dr Ohuchi and colleagues assessed the efficacy of adjunctive ultrasonography in breast cancer screening for Japanese women aged 40 to 49 years.

They enrolled 72,998 women between 2007 and 2011; 36,859 were assigned to ultrasound testing plus mammography (the intervention group), and 36,139 were assigned to the control group of mammography alone. Screening was conducted twice during a 2-year period.

The mean age of participants was 44 years; 3344 (4.6%) participants reported a history of breast cancer in first-degree female relatives, and 917 (1.3%) reported having had one or more benign breast conditions.

Mammography Alone (Control Group) Mammo + Ultrasound (Intervention Group)

Sensitivity 77% 91.1%

Specificity 91.4% 87.7%

Significantly more cancers were detected at screening in the ultrasonography group compared with the mammography alone group, at 184 and 117, respectively. And detected cancers were significantly more likely to be stage 0 or 1 in the intervention than in the control arm (71.3 vs 52.0%).

Fewer interval neoplasms were diagnosed among women in the ultrasonography group compared with those screened by mammography alone, at 18 versus 35, a significant difference.

The J-START investigators conclude that adjunctive ultrasonography could offer a low cost way to improve sensitivity and detection rates of early-stage cancers in women with high-density breast tissue and young women, groups in which the accuracy of mammography is reduced.

In a related commentary, Martin Yaffe and Roberta Jong, from the University of Toronto in Ontario, Canada, say that J-START is an important trial as it is “the first randomized trial of population screening with ultrasonography, and was done in asymptomatic women at average risk, who were not preselected on the basis of other imaging findings.”

Moreover, the trial was conducted in “relatively young women”, they say, adding that “despite evidence of mammography screening effectively reducing mortality in women in their 40s, this method is seldom recommended or provided for women younger than 50 years.

Studies are now beginning to show the benefit is even greater in women with dense breasts for whom the sensitivity of mammography for detecting breast cancer is decreased. Bottom line, the combination of screening mammography PLUS ultrasound improves cancer detection. There is always the concern about false positives and too many unnecessary biopsies, but detection is the first and most important step in our fight against breast cancer!

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA are


Screening Mammography Radiation Risk 35% LESS Than Thought!

The low risks from radiation exposure during mammography screening may be even lower than experts have assumed, a new study contends. The new research estimates that the radiation dose from a screening mammogram is anywhere from 20 percent to 35 percent lower than previously thought.

Why? Because past estimates did not account for the uneven distribution of different types of tissue in a typical woman’s breasts. The study was performed at the University of California, Davis and presented at the American Association of Physicists in Medicine. Lead researcher Andrew Hernandez, a Ph.D. candidate, noted that “the breast is composed of skin, fat and glandular tissue, and it’s the glandular tissue that’s potentially at risk from radiation during mammography.”

Past estimates have assumed that fat and glandular tissue are distributed uniformly throughout the breast, but recent research has shown that the different tissue types are actually more “mixed” than originally thought. As such, glandular tissue is actually exposed to about 30 percent less radiation, on average, than assumed.

According to Hernandez, the lower radiation dose provides reassurance to women concerned about the radiation exposure risk versus benefit of screening mammography. It has long been known that modern mammography uses low doses of radiation, and that any risk from regular screening would be greatly outweighed by the benefit of catching breast cancer early.

However, this preliminary research suggest that “a very low risk is even lower than originally thought.”

At Digital Mammography Specialists (DMS), the highly experienced clinical staff adhered to the as low as reasonably achievable (ALARA principle) for mammography imaging. Utilizing digital 2D and 3D tomosynthesis mammography allows DMS to minimize the concern from radiation and ensure the best imaging study for detecting breast cancer.

Lower radiation risk is just one more positive reason for women to obtain their annual screening mammogram. Screening mammography saves lives!

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA are


Screening Mammogram Starting at Age 40. Why It Works!

Recently, the American Cancer Society (ACS) announced its new screening guidelines that increase the age for annual mammograms for women of average risk from 40 to 45 years of age and biennial screening for all women between the ages of 55 to 74. ACS also stated that doctors should no longer perform clinical breast exams.

Retrospective analysis of numerous research studies led to this conclusion, HOWEVER the conclusion essentially ignores the basic fact and single most important message: MAMMOGRAMS SAVE LIVES. Period. End of story. The importance of receiving annual mammograms, beginning at age 40 — and possibly earlier for women with a history of breast cancer — is obvious. 1 in 8 (12%) women in the US will develop invasive breast cancer during their lifetime. Screening mammography is our best tool in the early detection of breast cancer. Catching cancer at its earliest stages leads to higher cure rates and decreased deaths. No one is disputing these simple facts.

U.S. breast cancer deaths have fallen 34 percent in the past 20 years — from 33 to 22 per 100,000 women between 1990 and 2011. And that represents 200,000 lives saved! At present, there are no tests to replace mammography. It is a crucial and life-saving tool in the fight against breast cancer.

The trouble with these new recommendations is that many women do not know if they are at “average” risk because they are not informed about their family history. This creates a false sense of security and puts many at risk by telling women they have an additional 5 years to be screened.

The longer women take to be diagnosed with breast cancer the more costly and painful the treatments and options. We should be encouraging detection, not discouraging it especially when the incidents of breast cancer are still at alarming numbers. With the high costs of health care, these new directives by the American Cancer Society will be viewed as an attempt to cut costs under the guise of best practices and its effect may put more lives at risk.

One major “harm” cited was the anxiety that could accompany a false-positive mammogram. The panel members reasoned that reducing anxiety by reducing screening was reasonable, which would allow women to die unnecessarily. To suggest that “anxiety” or “potential harm from false positives readings” is reason enough to change the screening guidelines is a misrepresentation. Today’s 3D tomosynthesis technology is reducing call backs and directly reducing false positives and unnecessary procedures. At Digital Mammography Specialists (DMS), our call back rates have dropped over 20% using 3D mammography. Instead of changing the guidelines, we should be aggressively promoting utilization of the latest technology in breast cancer screening for women starting at age 40.

All medical care is based on “overtreatment” since we are still unable to accurately predict who will benefit with certainty from any medical intervention. Regardless, screening leads to early detection, which saves lives. Screening is not responsible for “overdiagnosis.” Women should not be deprived of life-saving screening because of the cost or that the tool is not perfect in detection.

In conclusion, we need to stop the confusion. Of note, the ACS guidelines say that health insurers should cover all mammograms, regardless of the age of the patient or the frequency of the screening. The American College of Radiology (ACR) and Digital Mammography Specialists recommends screening mammography should begin at age 40. The evidence supports early detection. Screening mammography starting at age 40 is our best tool in the fight against breast cancer. It works!

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA area


Outpatient Imaging: The End is Near

Take a closer look at private and in-office outpatient imaging and you see an industry in a rapid death spiral. The federal government, big insurance companies, and large hospital corporations have conspired to aggressively “direct” patients to hospitals and hospital owned outpatient imaging centers for their diagnostic imaging needs. Frankly, I don’t see a silver lining for a problem that has only accelerated to the downside. The Deficit Reduction Act of 2005 and the Affordable Care Act of 2010 (Obamacare) clearly spelled out the mandate of the Federal government to eliminate the independent outpatient imaging industry as the answer, albeit incorrect, to controlling runaway healthcare costs. The idea that patients need or want a choice and will need independent non-hospital affiliated or physician based outpatient imaging services has become a myth. The majority of patients go wherever their insurer directs or their primary care / ordering physician recommends. Complex contracts between insurance companies and hospitals result in insurers paying more for imaging services performed by the hospital network but offset those costs through negotiated “discount” rates for other clinical services (outpatient surgery, ER, oncology, etc.) at the hospital. While there are a minority of patients who refuse to tolerate the hospital maze of parking lots, central scheduling, and lack of personalized service, these patients are too few to keep the doors open for independent outpatient imaging centers. Sadly, this is not the only problem plaguing the industry.

One must recognize that imaging technology is rapidly evolving as the age of big data and supercomputers continues to make huge advancements in visualizing disease and its effects on the human body. The capital investment for one piece of imaging equipment can be well over a million dollars. The expectation is that the lifespan of the equipment and steady reimbursement for services will provide a positive return on the equipment and support the overall outpatient imaging service. This is definitely no longer the case. The revenue generating life cycle for any advanced imaging equipment is shorter than ever before and the reimbursement for in-office / private outpatient imaging is lower than ever before. As such, the independent and private office imaging service falls behind in providing the expected image quality or can’t even perform the complex imaging exam requested. Not a problem for the hospital which can afford to upgrade and buy new equipment given their reimbursement levels for many exams can be three times higher than reimbursement rates for private and physician based outpatient imaging. Yet, the shorter life span of imaging equipment is a minor back ache compared to the cancer affecting the whole body of the independent outpatient imaging industry.

Hospitals have been on a tear in the last 10 years buying primary care and subspecialty practices as a way of driving healthcare dollars into their hospital network. Today, roughly 25 percent of all specialty physicians who see patients at hospitals are employed — a sizable increase from the 5 percent of specialists who were hospital-employed in 2000. The number of employed primary care physicians has doubled to roughly 40 percent during the same time span. Given the administrative red tape heaped on physicians, primarily from Obamacare, and the other ever increasing administrative hassles of owning and managing your private practice, it’s easy to see why doctors are choosing hospital employment. As the solo practitioner continues to disappear, so do the referrals to privately owned imaging centers. In its “big brother” role, hospitals employ administrative utilization teams to ensure employee physicians and their respective offices utilize the hospital owned imaging and clinical services for delivering every aspect of healthcare to their patients. Yet, this is not the main cause in the death spiral of private and physician owned outpatient imaging.

Ultimately, look no further than the recent deep cuts in reimbursement enacted for 2014 for non-hospital outpatient imaging. Global Imaging reimbursement contains two payment components, technical (reimbursement reflecting the capital cost and maintenance of the equipment plus the trained personnel to perform the exam) and professional (reimbursement to the physician for interpreting the exam). Changes to Medicare reimbursement are subsequently adopted by insurance carriers. As reimbursement drops from Medicare for any exam, there is an equivalent drop in reimbursement from insurance companies, as all insurance companies use Medicare as the “measuring stick.” An analysis published by VMG Health in March of 2014 clearly spells out the bad news for outpatient imaging:

From just 2013, reimbursement for complex imaging exams like MRI and CT, which as expected would pay more than a simple x-ray or ultrasound, is down 13 to 24%. Reimbursement for these exams has been systematically cut over the past five years with some exams paying 75% less than they did 5 years ago. Does this matter for patients? You bet. Private insurers’ hospital outpatient reimbursement can be up to three times higher than physician and private office reimbursement, and Medicare reported an 80 percent difference between the two. As rates increase, so does the financial burden to the patient. For example, a co-insurance on a diagnostic or therapeutic procedure could jump from $20 to $60 depending on the venue in which it is performed. Physician office reimbursement is not just lower than hospital outpatient reimbursement; it is often too low in general. Even worse, when hospitals buy physician practices with in-office imaging services, the hospital then bills and receives payment for those services at the higher reimbursement. This allows hospitals to pay big bucks to acquire physician groups knowing they can turn around and use their hospital network contract with the insurer to quickly gain back the dollars used to purchase the “investment,” whether the patient still use the physician in-office imaging service or is directed to the hospital or its outpatient center for the same imaging exam. Note, the professional component (the payment to the radiologist for interpreting the exam) has slightly improved, translation that CMS i.e. the Federal government wants radiologists to practice radiology but stay out of the imaging business. The last thing CMS or large insurers want is the doctors who deliver patient care to actually have any knowledge or understanding in how health care dollars are actually being spent.

So private and physician based outpatient imaging is not dying from just one mortal wound but actually by multiple wounds administered through federal legislation, primarily the Deficit Reduction Act and Obamacare, and action by big insurers and hospital monopolies. Is there a cure? Unfortunately not. Radiologists are selling or shuttering their doors and joining the ranks of hospital based radiologists. Physicians still operating their in-office imaging services can only do so if they themselves are able to appropriately order enough imaging exams to keep the service in the black, as seen in orthopedic offices with MRI machines. These will be the last to go, but eventually they will close also. It’s just a matter of time for many of those offices, as eventually the significantly decreased reimbursement rates for in-office exams and evolving technology will swallow any benefit associated with performing those in-office exams. Probably another reason that larger well established groups are cashing in before it’s too late, and selling their practices and becoming hospital employees. Those in the industry see the writing on the wall, but don’t want to admit it. Rather, they hold out hope that a miracle will save the day. There are miracles every day in medicine but not on the business side of healthcare.

In closing, as a radiologist who formerly owned an imaging center, I see the death of independent outpatient imaging as a huge loss to patient care and service. I personally enjoyed seeing patients at the front desk and calling doctors with results and being available 24/7 directly on my mobile phone. I did it not only because I cared passionately about my patients but because, like many small business owners, my imaging center service had to be perfect every time and, without a doubt, head and shoulders above the hospital based service.

Product and service are the life blood of any business. In imaging, the same product can now be easily delivered by numerous providers. Independent imaging centers could always count on their service as the valuable differentiator. But, service has also been systematically eliminated from the imaging industry and patient expectations forced low. Now, patients won’t or don’t know any better and with the herd mentality governing the forces in healthcare, this major change in the imaging industry will follow the same path as the home telephone, invaluable for 100+ years and then overnight, obsolete and forgotten.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a managing director and healthcare business consultant for King & Prat, a boutique firm that provides private equity placement and consulting resources to help businesses overcome operational challenges and develop momentum for growth.