Health care changes for under 40 and over 70 year old mammograms

Here are guidelines:

Early detection remains the primary defense available to patients in preventing the development of life-threatening breast cancer, although advances in imaging technology and disagreements over recommended schedules have complicated the issue of screening.

Guidelines

For women younger than 40 years, monthly breast self-examination (BSE) and clinical breast exams every 3 years have been recommended, beginning at age 20 years. The most widely recommended screening approach in the United States has been annual mammography beginning at age 40 years.^[1]

In November 2009, however, the US Preventive Services Task Force (USPSTF) issued updated breast cancer screening guidelines that recommend against routine mammography before age 50 years. The specific USPSTF guidelines can be summarized as follows:

• No requirement for clinicians to teach women how to perform BSE (grade D recommendation); this recommendation is based on studies that found that teaching BSE did not reduce breast cancer mortality but instead resulted in additional imaging procedures and biopsies^[2]
• No requirement for routine screening mammography in women aged 40-49 years (grade C recommendation); the decision to start regular, biennial screening mammography before age 50 years should be an individual one and should take into account patient context, including the patient's values regarding specific benefits and harms
• Biennial screening mammography for women between age 50 and 74 years (grade B recommendation)
• Insufficient current evidence to assess the additional benefits and harms of screening mammography in women aged 75 years or older
• Insufficient current evidence to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women aged 40 years or older
• Insufficient current evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as a screening modality for breast cancer

Despite the USPSTF recommendations, the American College of Obstetricians and Gynecologists (ACOG) continues to recommend counseling patients that BSE has the potential to detect palpable breast cancer and can be performed.^[3]

ACOG also continues to recommend adherence to its current guidelines, which include the following^[3] :

• Screening mammography every 1-2 years for women aged 40-49 years
• Screening mammography every year for women aged 50 years or older

Mammography

Mammography is a special type of low-dose x-ray imaging used to create detailed images of the breast. Mammography is currently the best available population-based method to detect breast cancer at an early stage, when treatment is most effective.

The 2 types of mammography examinations are as follows:

• Screening mammography: Performed in asymptomatic women
• Diagnostic mammography: Performed in symptomatic women; eg, when a breast lump or nipple discharge is found during self-examination or an abnormality is found during screening mammography

Although mammography remains the most cost-effective approach for breast cancer screening, the sensitivity (67.8%) and specificity (75%) are not ideal. Mammography combined with clinical breast examination (CBE) slightly improves sensitivity (77.4%), with a modest reduction in specificity (72%).

Ultrasonography

Ultrasonography is generally used to assist the clinical examination of a suspicious lesion detected on mammography or physical examination. As a screening device, ultrasonography is limited by a number of factors, most notably by a failure to detect microcalcifications and by poor specificity (34%).

Currently, it is recommended that ultrasonographic screening for breast disease be reserved for special situations, such as for highly anxious patients who request it and for women who have a history of mammographically occult carcinoma.

Magnetic resonance imaging

MRI has been explored as a modality for detecting breast cancer in women at high risk and in younger women. A combination of T1, T2, and 3-D contrast-enhanced MRI techniques has been found to be highly sensitive (approximating 99% when combined with mammography and CBE) to malignant changes in the breast.

However, breast MRI has limited use as a general screening tool, with a 10-fold higher cost than mammography and poor specificity (26%), resulting in significantly more false-positive reads that generate significant additional diagnostic costs and procedures.

Based on evidence from nonrandomized trials and observational studies, the American College of Surgeons (ACS) recommends annual breast MRI screening in patients with the following risk factors:

• BRCA mutation
• First-degree relative of BRCA carrier but untested
• Lifetime risk approximately 20-25% or greater, as defined by BRCAPRO or other risk models

Based on evidence of lifetime risk of breast cancer, the ACS recommends annual breast MRI screening in patients with the following risk factors:

• Radiation to chest when aged 10-30 years
• Li-Fraumeni syndrome and first-degree relatives
• Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives

Image library

Anatomy of the breast.

Being in the medical field and dealing with health insurance on a daily basis; with facilities that perform outpatient surgeries for preventative services, I would suggest calling your insurance company.  Ask the specific questions: 

What are my benefits for mammography?  Will you pay if there is a screening DX, will you pay if there is a family/personal history DX and is what if my age is lower than the recommended US Preventive Services Task Force (USPSTF).  They may pay for them earlier than the recommended ages if there is a personal or family history, but you will have to ask.  If it is a general screening because you want to get screened earlier than age 40, not because of a family or personal hx, then they probably won't pay. 

The company that I work for does the verification for patients, BUT the most of the time get general benefits, online, and don't talk to a CSR.  Each policy is different.  I have know some insurance companies to pay for preventative services at 100% if there is a medical DX, and nothing for preventative, some pay 100% for preventative and not medical.  Some pay for a family/personal HX dx if under the recommended age, but not if there is a screening/preventative.