Breast imaging is one of the most fast-paced specialties in all of healthcare. The technology is constantly evolving, groundbreaking studies are published every day and even the smallest change to screening recommendations is sure to make headlines throughout the country.

Jay A. Baker, MD, professor of radiology and chief of the breast imaging division at Duke University Medical Center in Durham, North Carolina, and the vice president of the Society of Breast Imaging (SBI), spoke with Radiology Business about some of the biggest topics affecting breast imaging today.

Read below for the full conversation.

Radiology Business: Breast cancer screening recommendations have been one of the hottest topics in all of healthcare for many years. From your years of experience and research, what current recommendations do you think are the best?

Jay A. Baker, MD: I fully support the American College of Radiology (ACR) and SBI guidelines recommending yearly screening starting at age 40. All of the groups that have put forward breast screening recommendations—the ACR/SBI, the U.S. Preventive Services Task Force (USPSTF), the American Cancer Society—all agree that the most lives are saved by annual screenings at the age of 40. That part is not controversial. So, then, what is the controversy? Why do groups have different recommendations? It’s because they put different weights on the perceived risks of screening and different weights on what they think the value of screening is to women in their 40s.

For a lot of patients and even for a lot of physicians, it is hard for them to accept the fact that breast cancer is a big deal for women in their 40s. To many, breast cancer appears to be a problem primarily for the elderly. But more women in their 40s are diagnosed with breast cancer than women in their 70s. And one-third of all years of life lost to breast cancer are from women diagnosed in their 40s. When I first read that number, I had to check it three times to make sure I read it right, but that is accurate. There is no doubt that breast cancer is an important health concern for women in their 40s.

We’ve seen more and more states implement breast density notification legislation, but nothing has passed yet on the federal level. What are your thoughts on this trend? Do you think a federal bill could be passed soon?

I have no insight on the politics of this, and I don’t think anyone can predict what Congress will do at any given time. These regulations are generally handled on a state-by-state level, so to have it handled on a federal level would be unusual. But at this point, it’s almost moot. I think there are only about 8 states left that don’t already have a breast density law in place or have one in the works, and those tend to be the less populated states such as Montana, the Dakotas and Wyoming. So, looking at the map, most of the population is already covered by breast density laws.

Given what is going on in general with healthcare in Congress, I would be surprised if there was a big appetite for adding more regulations for anything related to healthcare, especially when so many women are already covered on the state level.

Digital breast tomosynthesis (DBT) is gaining popularity in the United States, and states are starting to require insurance companies to cover the cost of DBT. What are your thoughts on this modality as it continues to gain popularity?

DBT is the rare win-win in medicine. There is no doubt, based on all of the studies that are out, that we find more cancer with tomosynthesis. It’s a definite improvement in sensitivity. And this isn’t a surprise, because it’s essentially a 3D mammogram, revealing breast cancers that were previously obscured by overlying breast tissue. But whenever you have an increase in sensitivity with new technology, you frequently see a matching decrease in specificity that shows up as an increase in unnecessary recalls and unnecessary biopsies. That doesn’t happen with DBT, so that’s why I call it a win-win. The sensitivity and the specificity both increase.

DBT also has a low recall rate. As a specialty, we recall somewhere in the neighborhood of 5 to 10 percent of women for additional imaging after a screening mammogram, and most of the time, it’s not cancer. We create anxiety when we do that, it can be expensive, and so on. But DBT leads to somewhere between a 15 to 30 percent decrease in recall rate, and that’s a big deal.

What about the costs associated with DBT? Do you see those as an issue?

Well, although there are only so many healthcare dollars to spend, there are actually studies out now that show DBT is cost-effective. Overall, you end up spending less on breast imaging if patients are screened with DBT than if they are screened with 2D mammography. How is that possible when DBT is more expensive? It’s because the recall rate is lower, which means fewer diagnostic mammograms and breast ultrasounds. And we also do fewer needle biopsies for patients screened with DBT. Taking all of those costs into account, it’s not a huge advantage—but it’s certainly not costing more to screen patients with DBT.

What is a common concern you hear about from SBI members and other breast imaging specialists? What does everyone seem worried about right now?

One of the main things our members are concerned about is insurance coverage for screening. According to the Affordable Care Act, USPSTF guidelines are used to determine the kinds of screening studies that get covered. And since the USPSTF recommends biennial screening starting at the age of 50, health insurance companies, in theory, could choose to only pay for that. Various provisions and laws have protected annual screening mammography, however, with a new extension being passed as the last one expires. The Protecting Access to Lifesaving Screenings Act (PALS Act) of 2017 is active now, but it’s a two-year deal that will run out on Jan. 1, 2019. So less than a year from now, the PALS Act will sunset again. What will Congress do then?

This is a big deal for our members, because they know that if insurance companies are not mandated to cover mammography yearly beginning at the age of 40, some of them won’t cover it. And that means, without a doubt, women will die unnecessarily.