More on Why Mammograms are “Mandated”

Hello bOObs Bloggettes:

I received a comment from a woman who said it wasn’t totally clear in one of my blogs as to why women had to get a mammogram before an ultrasound, lightly questioning my assertion that it was a “mandatory” prescription on the part of doctors. I know this topic is a wee confusing so I thought I’d dive deeper into this to explain further.

The Standard of Care (SOC) in breast cancer (BC) screening, that is, the guidelines most doctors follow in order to protect themselves from liability, is to first prescribe a mammogram — as this test is defined as the only “primary” BC screening tool in the toolbox currently.  All other tests have been deemed by the U.S. FDA as “adjunctive” tests (i.e., ultrasound, MRI and thermography) to the primary of mammography.

How did this come to be? Dean Ornish, MD, a prominent researcher and author, who I interviewed for my second film on non-conventional cancer therapies, succinctly explained how the SOC establishment gets underway in medicine. First, Medicare (the federal government body who is the largest insurance company in the U.S.) sets what they’re going to reimburse for a certain disease or medical test. Then all the other insurance companies generally follow Medicare’s suit. Of course, Medicare takes into consideration what researchers and doctors have declared work best in medicine. Then the SOC is based on the average treatment or test outcome of that research (it’s complicated).

In the case of BC screening, the FDA deemed mammography as the sole primary BC screening tool and all others as adjunctive tests, as stated earlier. Therefore, Medicare says that doctors must prescribe the primary test of mammography first ahead of all other adjunctive tests. This is how women got stuck in the mammogram merry-go-round and why women in the upper two categories of dense breast tissue (DBT) are really in a bad position. Because remember: The denser the breast, the more susceptible the breast containing this radiation-sensitive tissue is to radiation-induced cancer — yet these women are basically being “forced” to get a mammogram ahead of the ultrasound that they usually are called back for anyway due to suspicious findings or “we can’t tell due to DBT.” Most women are very upset about this predicament, including myself, as many fall in these top two DBT categories.

Dr. Ornish went on to explain that after Medicare sets its reimbursement schedule for a certain disease or test, then medical colleges pick up on it and then it will eventually (maybe) become part of the university’s curriculum for med students.  Seems a wee backwards, doesn’t it?

Now, the other part of this equation that I haven’t really discussed are the medical diagnostic codes used for diagnosis and billing purposes. While many codes exist, ICD is the most common, apparently. Wikipedia says this: “The International Statistical Classification of Diseases and Related Health Problems (ICD) is one of the most widely used classification systems for diagnosis coding as it allows comparability and use of mortality and morbidity data.”

This coding stuff is complicated and I’m not going to try to pretend that I have a firm grip on it, but I do know that it plays into this scenario of the physician having to prescribe a mammogram first, even if the woman has very DBT and wants to avoid radiation. I’ve had several women state that their brilliant doctors somehow figured out how to “prescribe around” the mammogram billing code and get the woman and her dense breasts into ultrasound without having to have a mammogram first — good for them, I say!  But most of us aren’t that lucky and most doctors can’t take the time out of their busy schedules to figure this out for the patient.

I want to reiterate that if women want to get a mammogram, that’s their prerogative — but they should be told about all the pros and cons beforehand. The same applies to all screening devices. It’s called Informed Consent and currently we don’t have it (see previous blog on this).

BOOBS BOTTOM LINE: Women deserve the right to choose, in consultation with their doctors, which screening device they want to receive, and all tests should be considered primary screeners and covered by insurance. Full stop.

Blog at you soon, thanks for reading and helping to spread the word!  (Please see the “share” links below.)  And we’d love to hear comments from you! (see below as well)

Stay healthy,

Megan

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

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