by Dr. Priti Shah, Director of Breast Imaging for VCU Health & VBCF Board Member
Fall is finally in the (cool, crisp) air. Yellow school busses abound. Against the clear blue sky, leaves are turning vibrant shades of red, orange, and gold. Pumpkin orange is everywhere. Yet for many, October evokes another color: pink, symbolizing Breast Cancer Awareness Month. For patients and their loved ones, breast cancer is a year-round reality, often overshadowed by the bright pink ribbons and fundraising campaigns.
The journey begins long before a diagnosis is confirmed. It involves scheduling tests—screening and diagnostic mammograms, ultrasounds, biopsies—and the agonizing wait for results. Each step can feel like a roller coaster ride, filled with uncertainty and anxiety. The experience can be exhausting—mentally, emotionally, physically, socially, and financially.
Screening vs. Diagnostic Imaging: The Difference and Its Challenges
For some, the first step is a screening mammogram. Mammography is considered the gold standard for breast cancer screening, significantly reducing mortality rates when performed annually for women over 40. Most health insurance plans cover screening mammograms for women at least 40 years old with no out of pocket costs like co-pays or deductibles under the Affordable Care Act. However, it is crucial to recognize that a screening does not provide a diagnosis. Nor do patients who feel a lump qualify for routine screening. Both situations require additional evaluations, which may include specialized mammogram views, ultrasounds, needle biopsies, and MRIs. Unfortunately, there is no national law requiring health insurance to provide coverage for these essential follow-up tests with no cost to the patient.
Financial Burden of Diagnostic Imaging
For the 10-12% of patients who are called back after an abnormal screening or present with concerning symptoms, the financial burden can be substantial. A 2023 study revealed that 21% of women would skip recommended imaging if faced with out-of-pocket costs. Another study indicated that higher cost-sharing in insurance plans correlated with lower utilization of necessary diagnostic imaging, particularly breast MRIs, which boast the highest cancer detection rates.
These statistics are not mere numbers; they reflect the experiences of real patients. As the Director of Breast Imaging for VCU Health, I hear weekly accounts of individuals canceling or missing diagnostic appointments due to financial concerns. For instance, one woman declined a diagnostic mammogram after her screening upon learning she would owe $1,500, not including the costs of potential follow-up procedures.
The Impact of Delayed Diagnostics
These financial hurdles, especially for underinsured patients or those with high-deductible plans, can delay diagnosis and lead to advanced cancer stages requiring more invasive and costly treatments. Another patient, after being called back from a screening mammogram for a 1cm lump, opted to go elsewhere for a “screening mammogram” 18 months later rather than proceed with a recommended biopsy at the time, ultimately facing a much more serious diagnosis of a cancer now triple the size, with lymph node spread—and so requiring more aggressive, costlier treatment.
I’ve also witnessed the life-saving impact of timely intervention. A 40-year-old mother received a stage 0 breast cancer diagnosis following additional imaging from her first-ever screening mammogram. Thanks to prompt follow-up testing, her prognosis was excellent, demonstrating the critical importance of accessible diagnostics.
The need for equitable coverage for breast imaging is clear, especially considering it is the most commonly diagnosed cancer in the Commonwealth and the United States. Recently, 20 states have enacted legislation prohibiting health insurance companies from imposing cost-sharing for medically necessary diagnostic and supplemental breast examinations. Similar initiatives have been implemented for colorectal cancer screening. The question arises: why not for breast cancer?
Costs of Delayed Diagnosis
Is it “simply” a matter of cost? If so, while up-front cost considerations are valid, it is essential to recognize the long-term financial implications of delayed diagnoses. More advanced cancers require longer, more expensive treatments and follow up, for which the financial (not to mention, physical and psychological) costs far exceed the cost of necessary diagnostic imaging.
And it’s not just diagnostic imaging widening the gap between the screening mammogram and diagnosis. As of September 10, 2024, the FDA’s Final Rule for Mammography mandates that all mammogram results inform patients, in plain language, about their breast density and recommend discussions with their healthcare providers regarding supplemental screening options for those dense breast tissue and /or elevated lifetime risk, such as ultrasound and MRI. Yet, there is still no requirement for insurance companies to cover these additional screenings that would aid in early detection.
Despite the challenges, there is hope. By organizing and focusing philanthropic efforts—and, more importantly, advocating for comprehensive coverage of breast imaging—the Virginia Breast Cancer Foundation is paving the way toward a system where early detection is not a privilege but a standard for all.
VBCF’s Legislative Efforts
Through its interwoven mission of access, education, and advocacy, VBCF has long championed legislation at both the state and national levels to alleviate the burden of cancer for patients in the Commonwealth. A recent state legislative initiative, House Bill 230, aims to eliminate out-of-pocket costs for diagnostic and supplemental breast imaging, such as MRIs, ultrasounds, and diagnostic mammograms. VBCF members and staff have actively collaborated with the bill’s sponsor, Delegate Shelly Simonds (VA-70th), engaged with legislators, conducted community education, and represented patient voices during testimony at various committee meetings as it has moved forward from the last two General Assembly sessions. VBCF is currently planning it’s work on this bill for the 2025 legislative session which will begin in January.
Expanding VBCF’s Screening and Diagnostic Fund
While awaiting policy changes, VBCF is committed to bridging the gap between screening and diagnosis. Through VBCF’s SWVA Screening and Diagnostic Fund, the foundation has invested hundreds of thousands of dollars to provide breast cancer screening and diagnostic services to uninsured and underinsured individuals, partnering with health systems in that area. This month, VBCF announced the expansion of it’s Screening and Diagnostic Services Fund to serve patients in Richmond, Petersburg and surrounding locations. In this way, their fundraising efforts create a tangible, direct impact on the lives of Virginians.
There is a substantial body of scientific evidence demonstrating that screening mammograms save lives. However, this benefit can only be realized when subsequent steps are taken to confirm a cancer diagnosis. Providing free screenings while leaving diagnostic procedures financially prohibitive leaves women in a precarious position, regardless of technological advancements, innovative treatments, and medical expertise. This reality exacerbates health disparities and inequities, a truth I witness daily.
A Call for Change Beyond Pink Ribbons
Organizations like VBCF are tirelessly working to provide financial support directly to patients and advocating for policy changes at both the state and national levels, such as HB230. This October, let us focus on more than just pink ribbons; let us commit to ensuring that every individual has access to early detection, effective treatment, and a brighter, healthier, more colorful future.
References:
Ngo M, Qureshi M, Kim G, Fishman MDC, Slanetz PJ. Effect of a high deductible health plan on patients’ willingness to undergo indicated breast imaging [published online ahead of print, 2023 Apr 4]. Radiology. 2023;222952. doi:10.1148/radiol.222952
Hughes DR, Espinoza W, Fein S, Rula EY, McGinty G. Patient Cost-Sharing and Utilization of Breast Cancer Diagnostic Imaging by Patients Undergoing Subsequent Testing After a Screening Mammogram. JAMA Network Open. 2023 doi: 10.1001/jamanetworkopen
Rosenkrantz AB, Hirsch JA, Allen B Jr, Harvey HB, Nicola GN. Identifying radiology’s place in the expanding landscape of episode payment models. J Am Coll Radiol. 2017;14(7):882-888. doi: 10.1016/j.jacr.2017.01.023 Mar 1;6(3):e234893. .2023.4893. PMID: 36972047; PMCID: PMC10043745.
