Supplemental breast imaging payment eligibility criteria may be leaving some women behind
Supplemental breast imaging eligibility criteria may be leaving some women behind, according to research published in JAMA Network Open.
Women with dense breasts face a fivefold higher risk of developing the disease than others, and such density also may mask tumors on mammography. Ultrasound and MRI can help to overcome this issue, but health insurers often don’t cover these exams, leading dozens of states to pass laws that address the loophole.
Researchers recently explored the impact of such legislation in Pennsylvania, which enacted its supplemental screening protections in 2023. They found the bill’s criteria may be overlooking some women, potentially underlining the need for modifications.
“The findings of this study suggest that policies for insurance coverage of supplemental screening based on breast density may have limited ability to improve early detection for black women,” radiologists Emily F. Conant, MD, Christine E. Edmonds, MD, and co-authors, with the University of Pennsylvania, Philadelphia, wrote Aug. 5.
For the study, researchers included both black and white women, ages 40 to 74, with no prior breast cancer history nor BRCA1/2 variants. They pinpointed those who underwent mammography screening at Penn Medicine between 2015 and 2021, with cancer outcomes ascertained through December 2022.
The final sample incorporated over 68,000 individuals including more than 38,000 black women at a median age of 57. Pennsylvania Act 1 mandates insurance coverage for women with extremely dense breasts or those with heterogeneously dense breasts, plus a greater than 20% lifetime breast cancer probability, based on the Breast Cancer Risk Assessment Tool (aka, the Gail Model).
However, fewer black women had extremely dense breasts (2.1% vs. 5.8%) and greater than 20% lifetime risk of breast cancer identified (0.7% vs. 6.4%) compared with their white counterparts. Consequently, the authors noted, black women were less likely to meet the eligibility criteria for supplemental screening (1.6% vs. 8.4%) compared to white women. The legislation’s eligibility criteria showed lower sensitivity but higher specificity for detecting false-negative mammograms among black subjects compared to white counterparts in one round of screening. Using heterogeneously or extremely dense breasts alone would detect more false negatives, the authors added, but with significantly more women recommended for MRI.
Penn Medicine experts noted that the 2023 state law is meant to eliminate co-pays, deductibles or co-insurance for supplemental screening for women meeting high-risk criteria. However, using breast density and the Breast Cancer Risk Assessment Tool, none of the black women with false-negative mammograms would have been eligible. That’s compared to 29% of white women with false-negative screens. Meanwhile, using BI-RADS (Breast Imaging Reporting and Data System) pooled breast density categories without lifetime risk score (i.e., extremely or heterogeneously dense) for supplemental screening would increase sensitivity for false-mammograms but result in a “very large number of MRIs or ultrasonography scans for both black and white women.”
Penn Medicine experts acknowledged the legislation was not meant to address racial disparities in breast imaging. However, they believe “proactive evaluation” of this and other such policies is needed to prevent them from inducing or exacerbating existing disparities.
“Improved current approaches as well as exploration of novel risk factors are needed to identify black women at risk for false-negative mammograms who might benefit from supplemental screening,” the authors charged. “There is a need for risk models that more accurately estimate risk for black women, including existing models that could incorporate quantitative measures of density or other novel biomarkers, using artificial intelligence algorithms that can reduce false-negative mammograms. We acknowledge that disparities in breast cancer mortality are complex and that successfully addressing each disparity will require multiple interventions with concerted efforts from lawmakers, lobbyists, scientists and clinicians.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.