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    Breast density laws: Are you in compliance?

     

    Case 1 

    A 45-year-old woman had an appointment with her ob/gyn for an annual examination. She had no complaints and no family history of or risk factors for breast cancer. As part of the patient’s check-up, her physician performed a breast examination. It revealed no breast masses, nipple discharge, tenderness, or any other pathology. A screening bilateral mammogram recommended and ordered by the ob/gyn was performed.

    The patient later received a letter from the radiologist that stated in bold at the top of the page, “We wish to inform you that the results of your recent mammography examination are normal.” Below, within a descriptive paragraph, it said, “Your mammographic breast density is considered dense. Dense breast tissue is a common finding and is not abnormal. A report of your results was sent to your physician.” The letter did not say anything about further discussing the significance of increased breast density with a provider.

    The ob/gyn received a different mammography report from the radiologist, which stated that the screening mammogram was classified as “BI-RADS 1: Negative evaluation.” Listed under Impression were “1) No mammographic evidence of malignancy in either breast.” and “2) A bilateral mammogram is recommended in one year.” Within a descriptive paragraph in the body of the report was a statement “The breast tissue is extremely dense.” The ob/gyn was not provided with the letter that had been sent to the patient.

    Image courtesy of Debra Somers Copit, MD, FACR

    The ob/gyn, who knew about the requirement to notify a patient and offer additional breast imaging to patients with increased breast density, searched through the provider report to determine the patient’s breast density category. She then called the patient to discuss her increased mammographic breast density and offered her the option of additional breast imaging, either magnetic resonance imaging (MRI) or ultrasound. The patient initially was confused about why the ob/gyn was offering additional breast imaging, given the results letter from the radiologist telling her that her mammogram was normal. After the patient talked with her ob/gyn about her increased breast density, she asked to undergo a bilateral breast MRI despite having no symptoms.

    Because the woman’s healthcare insurer was not required by state law to pay for additional testing, coverage was declined for the MRI and the ultrasound, with the rationale that additional breast imaging was not clinically indicated. The patient still had the option of undergoing additional imaging with an MRI or ultrasound but would be personally responsible to pay $2400 or $250, respectively.

    The patient was unable to afford the additional imaging out of pocket. She remained anxious and upset about the alerts of her increased breast density on screening mammography.

    Case 2

    A 49-year-old asymptomatic woman with a recent normal check-up, including a breast exam, was referred by her ob/gyn for a screening bilateral mammogram.

    The patient later received a letter from the radiology center that stated in bold at the top of the page “We wish to inform you that the results of your recent mammography examination are normal.” Below, within a descriptive paragraph, it also said, “Your mammographic breast density is considered dense. Dense breast tissue is a common finding and is not abnormal. A report of your results was sent to your physician.”

    The ob/gyn received a mammography report from the radiology center, which said that the study was classified as “BI-RADS 1: Negative evaluation.” Listed under Impression were “1) No mammographic evidence of malignancy in either breast.” and “2) A bilateral mammogram is recommended in one year.” Within a descriptive paragraph was a statement, “The breast tissue is heterogenously dense.” The ob/gyn was not provided with the letter that had been sent to the patient.

    Also read: Are breast density letters too dense?

    The patient, believing that her “normal” mammogram required no additional action, did not contact the ob/gyn for further discussion. No further action was taken by the ob/gyn, either because he was not aware of the state law that required notification and an offer of additional imaging to patients with increased mammographic breast density, he did not notice the finding of increased breast density in the otherwise normal report, or he believed it would be taken care of by the radiologist.

     

    Jay Goldberg, MD, MSCP
    Dr. Goldberg is a Professor of OB/GYN, Vice Chairman, and Director of the Philadelphia Fibroid Center at Einstein Medical Center ...
    Sara Mirghani, MD
    Dr Mirghani is a Resident in the Department of Obstetrics and Gynecology at Einstein Medical Center, Philadelphia.
    Sarah Woodman, MD
    Dr Woodman is a Resident in the Department of Obstetrics and Gynecology at Einstein Medical Center, Philadelphia.

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