Mammography: 'Gold Standard' Could Use Some Polish
On the other hand, doctors don't yet have extensive experience interpreting MRIs of the breast, so it's not clear just what would constitute a normal or abnormal test.
Another issue discussed in the report and debated among experts is whether the current insurance payment rate for mammography services is adequate. The Medicare and Medicaid reimbursement rates for mammography don't cover the full cost of the expensive test, and private insurers may pay even less, causing some to wonder if radiologists and technicians will want to continue performing the service.
"Some experts caution that the availability of mammograms could be shrinking. ... As a result women in this country are often forced to wait weeks or even months for their annual breast cancer screening because of scaled back or closed mammography centers. These delays can result in more advanced and less treatable forms of breast cancer," says Sen. Tom Harkin (D-Iowa).
To thwart reduced access to mammography, Harkin, along with a bipartisan group of legislators, plans to introduce this week a new bill that would increase the mammography reimbursement rate. Currently Medicare picks up most of the tab for the service.
And what about the controversial question of when to start breast cancer screening? It could be a life or death question. The IOM report didn't weigh in on that, but a few things are clear. The expert consensus is that all women aged 50-69 should get the test annually.
Debate continues about the right approach for women aged 40-49. The National Cancer Institute recommends women get a mammogram in their 40s with repeats every year or two. The American Cancer Society urges women to go for their first mammogram at age 40, then have one each year thereafter.
"I think from the NCI's perspective you've got evidence that shows benefit for screening between every 12 and 24 months. From our perspective, we see much better results in the trials that screen" every 12 months, says Smith. While there are fewer tumors in younger women, he says, they spread more rapidly.
Kramer doesn't see a simple right or wrong in the guidelines -- personal choice is a part of the equation. "Sometimes the complexity of the information doesn't necessarily justify complete agreement amongst all organizations," he says.
Meanwhile, according to a spokesperson for the Health Insurance Association of America, that organization's companies always pay for annual mammograms after age 50; for younger women it varies depending on need.
Susan Pisano, a spokeswoman for American Association of Health Plans, says HMOs follow another federal guideline that says the evidence is insufficient to recommend mammograms in younger women. "In terms of the health plans, they get very aggressive with mammography and other screening tests when you are a member of a group that's [recommended for testing]," says Pisano.