In the latest example of value vs. cost in medicine, many medical centers must decide whether they should invest hundreds of thousands of dollars in new breast cancer screening and detection technology.
The choice comes after several developments in the past two weeks about breast magnetic resonance, or MR, machines, and computer software that works like a spellcheck to enhance the reading of mammograms.
In an announcement expected to further accelerate purchases of expensive MR equipment, the American Cancer Society released guidelines in late March that recommended breast MR tests for an estimated 1.4 million American women who carry the highest risk of breast cancer, either because it runs in their families, they have certain gene mutations or they have had chest radiation.
Breast MR also is used in women already diagnosed with breast cancer to see if they have signs of cancer in their other breast. Three percent of the time they do, according to a March 27 study published in the New England Journal of Medicine of nearly 1,000 women with breast cancer who had MR tests. MR machines produce computer-generated pictures of the breast's interior with magnetic fields and radio frequency waves.
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The other announcement was a setback for software known as computer-aided detection, or CAD, systems. A study in the April 4 issue of the New England Journal of Medicine found that CAD systems made the reading of mammograms more inaccurate.
CAD software leads to unnecessary biopsies because it suggests cancer is present when it is not, the study concluded. For each woman whose cancer was found with CAD technology, 156 were wrongly recalled for more tests and 14 had biopsies they didn't need, the authors from the National Cancer Institute and the University of California Davis Health System, Sacramento, said.
CAD would add 18 percent to mammography costs, an additional $500 million nationwide if all U.S. centers added the technology, the study's author estimated. "It's unfortunate that CAD technology proliferated so widely before we are certain of its benefits," the report concluded.
The stakes in the new debate are high.
Breast screening and cancer care are among the more competitive services hospitals offer. Many medical centers heavily promote their services and spend heavily to upgrade the programs. The equipment is costly. CAD systems cost $100,000. MR machines range from $900,000 to $2.5 million, depending on the strength of the magnet used.
There are other issues. Breast MR tests aren't regulated by state or federal standards, as mammograms are, though the American College of Radiology is developing standards that may come as early as next year. And costs vary widely, as often occurs when new technology enters medicine.
A recent telephone survey of 80 breast centers found MR costs, which often are covered by insurance, including Medicare, ranged from $1,150 in Utah to $9,000 at one Pennsylvania center, with most averaging around $2,000 for an exam of both breasts, according to Dr. Renee Carter, senior fellow and medical adviser for the National Research Center for Women & Families, a Washington, D.C., advocacy group. That's about 10 times the price of a routine screening mammogram -- ones done yearly to find cancer.
Breast cancer specialists at three centers with the technology say the new findings show that new technology has its place at a top center, but that mammography remains the primary way to find cancer.
Breast MR "is a complementary exam," explained Dr. Sophia Roumanis, medical director of imaging for the Oakwood Healthcare System. Enough women have family risk of breast cancer or carry genes that make their risk of getting it higher that "we're updating our technology to support the demand," she said.
Dr. A. Christine Watt, director of breast imaging for St. John Hospital and Medical Center, offers both technologies among tools to improve breast cancer detection. "If you have a tool which will assist you, and you remember it's a tool, then these items are very helpful. But if you use them for the eyes and ears of a radiologist, they likely will increase the number of biopsies."
To save money, St. John and many other hospitals have held off purchasing an MR machine solely used for breast cases. Instead, they buy add-on equipment for machines used for a wide range of tests.
The hospital does only about three or four breast MR tests a week, Watt said. "I don't see the public beating down the door for it."
The new ACS guidelines may fuel more requests for the tests, said Dr. Murray Rebner, radiology chief at Beaumont Hospital in Royal Oak, Mich., where 700 women undergo the tests a year. "There definitely will be increased demand."
Nealie Hartman, clinical marketing manager, MR division for Siemens Medical Solutions, in Malvern, Pa., said about one fourth of medical centers with MR machines offer breast MR tests. After MR angiography, breast MR is the second fastest growing use of the technology. With the new ACS guidelines, "we expect the growth rate will just explode."
SHOULD YOU GET TESTED?
Breast magnetic resonance tests vary widely in cost and quality. Here's what women need to know:
Who should get MR tests?
They are recommended along with mammograms, beginning at age 30 for women at high risk of breast cancer or those who have had prior chest radiation, according to the American Cancer Society.
What does it cost? Does insurance cover it?
Costs are $1,000 to $2,500, depending on whether one or both breasts are tested, and whether contrast dye is used. Medicare and most insurance plans cover the procedure.
Where should a woman get the test?
Go only to centers that have equipment dedicated for breast use, either the machine itself or technology added to an MR machine. Ask who reads the tests, whether the center is accredited by the American College of Radiology, and whether it meets state and federal standards.
For more information: go to the American Cancer Society, www.cancer.org or the American Society for Clinical Oncology, www.asco.org.