Maryland mammography law turns incidental cardiac findings into a new screening opportunity
Maryland became the first state Oct. 1 to require women to be notified about breast arterial calcifications (BAC) identified on mammograms, creating a new pathway to piggyback opportunistic cardiovascular risk assessment on these routine breast cancer screenings.
The law (House Bill 1364) reflects growing interest in using existing imaging studies to identify cardiovascular disease risk without requiring additional scans, radiation exposure or costs. It also could serve as a model for other states as radiology and cardiology organizations, including the American College of Radiology (ACR) and American College of Cardiology (ACC), push for wider use of opportunistic screenings like this.
Radiology Business spoke with Michael Coords, MD, medical director of cardiovascular imaging at RadNet and incoming co-chair of the Society of Cardiovascular CT (SCCT) Health Policy and Practice Committee, about how BAC provides potentially valuable information about a woman's cardiovascular health.
“By opportunistically identifying breast arterial calcifications on routine mammograms, we have an unprecedented, noninvasive opportunity to catch the early warning signs of systemic cardiovascular disease years before a catastrophic event occurs, and we're doing it without extra radiation or added cost to the patient," Coords explained.
BAC is different from coronary artery calcification. Breast arterial calcification primarily reflects calcification of the medial layer of arterial walls, while coronary calcium is generally associated with atherosclerotic disease in the intimal layer. However, research has demonstrated an association between BAC and cardiovascular disease, including peripheral vascular disease and stroke, Coords said.
The finding can be particularly useful when considered alongside traditional risk factors such as hypertension and diabetes. A woman with extensive BAC but few other recognized risk factors may warrant a closer assessment of her cardiovascular risk. Increased cardiac screening through mammograms could save more lives, Coords said. Cardiovascular disease is the leading cause of death in women 30-35, more then all cancer’s combined.
Unlike coronary calcium scoring, BAC currently does not have an established equivalent to the Agatston score that quantifies the amount of coronary calcification. Coords said the most practical current approach is to report whether BAC is present because it indicates increased cardiovascular risk.
Over time, automated technologies may provide more quantitative measurements, but Coords believes the immediate priority is ensuring women and their physicians receive this additional risk assessment information.
He also cautioned that BAC should not be interpreted as evidence that a cardiovascular event is imminent.
“When a woman in Maryland reads ‘breast arterial calcification’ on her mammogram, our most critical message is what this finding does not mean,” Coords said. “It is not breast cancer, and it does not mean a heart attack or stroke is imminent.”
Instead, the finding can turn a routine mammogram into an additional opportunity to discuss long-term cardiovascular health with a primary care physician.
One issue with Maryland's law, however, is the wording surrounding patient notification. According to Coords, the legislation appears to require a patient-facing letter discussing BAC even when no BAC is identified on the mammogram. That could create unnecessary anxiety and confusion, he said.
Coords believes the BAC-specific patient letter should be triggered when calcifications are actually present. At the same time, the absence of BAC should not be interpreted as proof that a woman has low cardiovascular risk.
RadNet prepared for the Maryland requirement while also moving toward broader standardization of BAC reporting across its markets, rather than waiting for individual states to enact similar legislation.
The company also has worked with the American Society of Radiologic Technologists (ASRT) to provide continuing education for mammography technologists on BAC. Technologists can be among the first members of the imaging team to receive questions from patients about the finding.
Maryland's law may accelerate adoption elsewhere, but Coords said the underlying rationale extends beyond regulatory compliance.
“We want to make sure women have access to this information as an additional data point,” he said. “Every state really should be reporting” BAC because early identification of cardiovascular risk can provide an opportunity for prevention and further evaluation.
To see breast artery calcification imaging on mammography and hear more details, watch the video above.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]