Good intent, bad execution on breast-health law

Radiologist Debra Copit disagrees with a law requiring mammography centers to notify women about breast density.
Radiologist Debra Copit disagrees with a law requiring mammography centers to notify women about breast density. (APRIL SAUL / Staff Photographer)
Posted: November 07, 2013

Great news: Pennsylvania recently passed a law to improve women's health. Alas, it is based on faulty science and lacks funding.

On Friday, right after the pink-ribboned month of October, Gov. Corbett signed into law the Breast Density Notification Act. The law requires mammography centers to notify women about breast density so they might consider further tests such as ultrasounds and MRIs. Denser breasts appear white in mammograms, as do tumors, making them more difficult to read.

But does that mean women with denser breasts are more likely to get cancer?

Pat Halpin-Murphy, founder of the PA Breast Cancer Coalition and a chief advocate for the law, told me, "There is science that dense breast tissue can increase your risk for breast cancer."

But Debra Copit, director of breast imaging at Einstein Medical Center, disagrees: "There's no good scientific evidence that if you have denser breasts, you're more likely to get breast cancer."

Copit speaks from experience. She has done studies on breast density in 90,000 women. A breast cancer survivor, she is among the 10 percent of women who have extremely dense breasts.

"I don't get the extra tests," she told me. "I am a physician. I am a scientist. I base my decisions on science, not emotion or anecdotes."

Here's an additional problem: If a woman has inadequate insurance or none, Pennsylvania will not pay for the additional testing.

Last year, the American College of Radiology raised concerns about breast density notification legislation, now law in 12 states and pending in 18 more, including New Jersey. The society warned of the "possible harms and unintended consequences" of such mandates, chiefly false alarms, unnecessary biopsies, a false sense of security among women with less dense breasts, and research that additional screening will not necessarily save lives.

Determining density is not an exact science, either. Dense breasts are both common and normal: 80 percent of women have a mix of dense and fatty breast tissue.

"State legislatures are passing laws that ultimately turn out to be very bad medicine," said the American Cancer Society's chief medical officer, Otis Brawley. "I am worried about the financial and emotional harm, as well as the inconvenience, that these additional tests might cause."

In 2009, Connecticut passed the first density notification law but requires insurance coverage for additional ultrasounds. That state law led to substantially more tests, and the detection of three additional breast cancers for every 1,000 women screened. But the flood of ultrasounds also led to a spike in false alarms and unnecessary biopsies that found no cancers, far more than occurred with mammography.

Pennsylvania's new law requires centers to tell women about their breast density, which leaves underinsured and uninsured women to fend for themselves. Unlike Connecticut, the state did not consider providing insurance. Prices vary widely - another challenge for the uninsured - but a breast ultrasound screening can cost $300, Copit told me, and an MRI can have a $2,000 price tag.

The Corbett administration is negotiating with federal officials to expand Medicaid on the governor's terms, but there is no certainty that will be approved.

"It's OK to tell people to have more tests, but who is paying for it?" Copit asked. "We could end up with a two-tiered system of women who have insurance getting supplemental screening, and those who pay out of pocket being left out."

We already have a two-tiered system. Actually, multiple tiers.

Women struggling with inferior insurance, or none, aren't likely to get better health care. "Without Medicaid expansion, legislation that is well-meaning but scientifically flawed and politically popular has the potential of increasing health-care disparity among poor people," Brawley said.

Breast cancer can be a killer, but heart disease and lung cancer pose greater risks for women. Why aren't legislators raising taxes on tobacco, increased prices a proven incentive to quit smoking? Why isn't more being done about heart disease? It seems to me paternalistic that the legislature passes a law, at no expense to the state (or political cost to elected officials), that tells mammography centers what to tell women, and based on bad science at that. But, go ahead and have a nice news conference, as the governor did Friday, bathed in the softness of pink lights.

"The role of government is to guarantee health care as a public good, to guarantee health care as a right, and that everyone can access it," said Gene Bishop, a women's health-care activist, retired internist, and breast cancer survivor. "The role of government is not to practice medicine."

If Pennsylvania really wants to help more women, the governor should accept Medicaid expansion, and without delay, exceptions, or the creation of a complicated, new model that will make it harder for poor people to get the better care they deserve.

215-854-2586 @kheller