“Why do I have to get a Mammogram before an Ultrasound?” 2

Hello bOObs Bloggettes:

I’m reposting this in honor of International Women’s Day as it’s a topic that many, many women on my “bOObs” Facebook page (and elsewhere) ask me about; also, it received much response when last posted. Women want to know:  Why do I always have to get a mammogram before an ultrasound, even if I have dense breasts?

This is an excellent question and I’ll do my best to answer it based on what I’ve learned from MDs and other women who have looked into this mystery. First know that 90% of us have some degree of dense breast tissue, with only 10% of us categorized as having “fatty” breasts. (Who these 10% of women are I’ll never know as I’ve never met one — another mystery!) That leaves the other 90% of us with some degree of density, which is of concern because this tissue on a mammogram appears white — and cancer on a mammogram also appears white. Therefore radiologists have a heckuva time differentiating between the two. (Another blog explains that the denser your breasts, the more they crank up the radiation to “see through” the dense tissue — and no one is telling us that.)

So many of you have already been told by your doctors or your mammogram report that you indeed have dense breasts. But most of you were probably not told what that means — which is exactly what happened to me. In any event, it boils down to this: The mammogram has difficulty finding cancer in your dense breasts and many times can miss tumors, some even in late stages. Some women will be told by their OBGYN (if that doctor is on the ball) to go get an ultrasound when their mammogram report shows high density. Why? Because the ultrasound oftentimes does a better job at differentiating the cancer from the dense tissue — almost 50% better for women in the highest category.

Many of you are now thinking this: Then why, if I have really dense breasts, do I have to get a mammogram first if they’re going to order an ultrasound anyway? Can’t I somehow avoid the radiation?  The answer comes down to two things: The insurance reimbursement schedule and what’s known as medicine’s Standard of Care (SOC).

The SOC is what doctors basically must (or should) follow if they don’t want to get in legal jeopardy. It was explained to me by a crackerjack lawyer I interviewed in this way: View the SOC as a type of average that doctors follow that act as guidelines, giving them the best legal coverage if something should go wrong. So OBGYNs are most always going to tell a woman she MUST get a mammogram before she can get an ultrasound, even if the woman knows she’s in a high density category and the mammogram will do close to zilch in catching a cancer OR she wants to simply avoid radiation (of which there is plenty in a mammogram; see blog on this). It’s also a way for the OBGYN to hide behind the excuse of “Oh sorry we didn’t see your cancer before now, but I did order the mammogram, so my a** is covered by the Standard of Care.”

So the medical establishment’s SOC is one problem, but the other is insurance coverage for breast cancer screening tests. Medicare (the federal government’s insurance company), I’ve come to learn, basically sets in stone what is going to be covered by its insurance and then private insurance companies usually follow Medicare’s suit. So somewhere along the line, Medicare got it in their bureaucratic heads (maybe some lobbying entities put it there?) that women MUST have a mammogram before an ultrasound if the woman wants the ultrasound covered by insurance — again, even if the ultrasound would be more likely to catch a cancer in her dense breasts.

If a woman is lucky enough to be able to afford paying for an ultrasound on her own (around $150-$300 or so), then that’s her prerogative. But unless your doctor is smart enough to figure out a way around the billing codes to get the ultrasound covered without having a mammogram prior — and I’ve heard some women say this does happen on occasion — then the woman will not get reimbursed for an ultrasound regardless of her breast density. But it doesn’t hurt to ask!  (And my guess is that they get asked a lot.)

What I’ve come to learn after studying these issues for some six years now is this: It’s simply crazy what is happening out there in the breast cancer screening world and much of it isn’t based on an inkling of common sense. We need to get the decision-makers on Capitol Hill (many of whom are thankfully now women! :))) to understand what’s really going on and to help change it.

Help spread the word so we can build a bOOb coalition to change such non-sensical situations for women! Together our voices are strong.

Please feel free to comment on this blog below. Let’s learn from each other’s experiences.

Blog at you soon, thanks for reading and helping to spread the word!  (Please see the “share” links below.) 

Stay healthy,

Megan

Megan Smith, M.S.
Director, bOObs: The War on Women’s Breasts

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