Are You Dense?

Sometimes comedy and healthcare collide. I caught an episode of the Ellen DeGeneres Show recently where her guest that day was one of my favorite comedians, Wanda Sykes. Sykes was there, in part, to discuss her recent battle with breast cancer, a disease she found out she had quite by accident. Apparently Sykes had gone in for a voluntary cosmetic breast reduction (this is the cue for men everywhere to gasp in horror) and after the procedure it was discovered that the tissue removed, which is routinely examined after such procedures, was cancerous.

If you have extra time, you can watch the actual 4 and a half minute Ellen-Wanda interview by clicking HERE.

In the interview, Sykes talked about how, given her personal risk factors for breast cancer and her unwillingness to live fearing it’s sudden return, she decided to undergo a prophylactic double mastectomy in order to ensure she would not end up with breast cancer in the future.  It is an extreme decision, but one that is being taken more often by women willing to trade off body parts to avoid living in fear and submitting to extreme and ongoing diagnostic procedures for the rest of their lives.

I loved the part of the interview where Sykes says she was unsure whether she wanted to speak publicly about her breast cancer experience because she didn’t want to be the poster child for the issue.  She says, “How many things can I have?  I’m black, I’m lesbian, I can’t be the poster child for everything?  At least for the lesbian thing we get a parade…I was hesitant to do this because I hate walking. Now I got a lot of walks coming up.”

What particularly struck me about the story was that Sykes had been getting regular mammograms but the cancer had not yet been detected. This is, unfortunately, not an unusual story. I do not know the details of Sykes particular medical situation, of course, but one of the primary reasons that early breast cancers go undetected in women having regular mammograms is that they happen to have dense breast tissue. This is basically a type of body tissue found routinely in one out of every three women, so it is by no means unusual.  Furthermore, any radiologist reading any standard mammogram can basically tell right away if a woman has dense breast tissue.  And it so happens that when you happen to be one of those women with dense breast tissue, you might as well have a prostate exam instead of a mammogram because the two tests will tell you exactly the same thing about your breast cancer risk:  nothing. Mammograms are virtually incapable of seeing early stage cancers through dense breast tissue because the tissue obscures the pictures–it’s like finding a needle in a haystack.

Sorry about the graphic pictures (live nude girls) , but below is a pair of images that shows the remarkable contrast between a mammographic image of a woman with dense breast tissue and an alternative form of imaging used on the same woman that is far more effective (molecular breast imaging-see more on this below). You don’t have to have an MD from Harvard to see how profound the differences in these images are.  Yes, the large white spot in the molecular breast imaging picture on the right is the cancer.

So here’s the problem. In the current world, the typical woman doesn’t know to ask their doctor if they have dense breast tissue and the typical physician either doesn’t know enough about this issue to inform the consumer or, if the physician is knowledgeable, educates the woman about her situation and/or directs her to seek an alternative method of breast cancer screening (and yes, alternatives do exist) less than 10% of the time.  This means that about one out of every three mammograms done for annual screening results in a meaningless result and a cost to the healthcare system that provides exactly zero value in return. Perfect.  It also means that many breast cancers go undetected at an early stage when the chances of a better outcome from treatment are higher and the cost to treat is typically lower.

There is a movement afoot in America, sponsored by consumer organizations and doctors in the know, that would make it a legal requirement that physicians let those women who have dense breast tissue know it so they can access alternative forms of screening for breast cancer. I have written about this issue in the past, but between seeing Sykes and, more importantly, being stunningly disappointed that the State of California did not let this bill become law, I felt it needed revisiting. The law requiring that women be informed about their breast density and alternative methods of screening did pass in Texas.  Really Governor Brown?  We’re going to let Texas make us look like a healthcare backwater?  How embarrassing.

A while back the law passed first in Connecticut, where it was championed by the former Governor who had a personal experience with breast cancer that catalyzed her efforts to make her state an example for women’s health. The law is up for review in other states now, including New York, Pennsylvania and Virginia.  Even better, a federal law, the Breast Density and Mammography Reporting Act of 2011, was introduced in October to ensure that all American women have a right to information about their breast density; this is critical information, because women with dense breasts are up to 6 times more likely to develop breast cancer than other women.  If you like breasts and live in the United States, do yourself and your female friends a favor and write your state representatives, governors and congresspeople to urge them to support these bills. You can learn a ton about this whole issue at AreYouDense.com, a website dedicated to education and advocacy about issues surrounding dense breast tissue and breast cancer.

Clearly the state and federal governments are in a mode to reduce healthcare costs and it is true that the alternative methods of breast cancer screening are more expensive than mammograms.   Mammograms cost about $100-$300 on average.  MRIs cost anywhere from $1000-$3000 a piece; a new technology, molecular breast imaging (also a scan), costs around $300-$500 and has been demonstrated to be as good or better than MRI.  But the way I figure it, a woman with dense breasts could have years of useless $200 mammograms and, upon learning she has advanced breast cancer, cost the healthcare system an additional damned fortune in treatments that could have been avoided. We may have to spend a bit more to screen one third of women, but the payoff should be significant if we can avoid other unnecessary tests and interventions.  The average cost of treating advanced breast cancer is estimated between $35,000-$100,000 and that doesn’t include long term costs associated with a myriad of common side effects post-treatment.  Seems like a good trade-off to pay for early screening if it brings the cost of treatment down to the much lower level associated with treating breast cancer at an early stage.  FYI, 200,000 American women are diagnosed with breast cancer every single year.  How messed up is that?  It is worth noting that, for women with dense breast tissue, MBI is so good at identifying early stage tumors – even as small as 3 mm — that annual exams may not be necessary.  This means less frequent tests could be performed which would bring the average cost of screening for these women down to $150-250 per year relative to the $100-200 it now costs the system every year to provide them with a meaningless mammogram.

I find it ridiculous that our governments are debating whether they should require women to get essential health information.  If they really want to be useful here, they should start by refusing to pay for useless mammograms.  There are over 37 million mammograms performed in the U.S. each year and about 1/3 of those, or about 12 million, are a complete waste of time since they are performed on women with dense breasts.  Since breast density is a fairly objective measure that doctors can see after a first mammogram, it would be easy to say that women with dense breasts should not be eligible for reimbursement for this procedure as a money-saving measure.   The federal government, working through the U.S. Preventative Services Task Force, has already been trying to reduce the number of unnecessary mammograms by moving the age at which the screening is recommended from 40 to 50 on the grounds that many of these screenings lead to unnecessary interventions where there is really no cancer.  Given that stance, they may as well go all in and get rid of all of the screens that incur cost and deliver no useful information to help improve women’s health.  Should they succeed in doing that, however, they must to replace the useless screening option for women with dense breasts with something that can provide useful and actionable data.  As noted above, there are alternatives available now that work well for this purpose.

In the interests of full disclosure, my firm has an investment in a company, GammaMedica, which has an FDA-approved molecular breast imaging (MBI) system called LumaGem.  MBI is one of the most effective alternative screening modalities for women with dense breasts. The reason we invested in it is because we want to live in a world where the medical technology we support actually improves the lives of patients while reducing healthcare costs. The positive impact on patients needs no further comment.

Not to go all feminist on you, but I cannot imagine a world where physicians are permitted to keep such critical information about prostate cancer from men, either intentionally or unintentionally. I was in a board meeting today where an expert on such matters said, “the only reason that prostate surgery isn’t the most common surgery in men is because they only have one prostate.” I mean seriously, there is so much education and publicity out there about prostate issues from screening to drugs to treatment alternatives that my 15 year-old daughter could probably explain your options to you just from what she learned watching the MLB play-offs. But when it comes to the risks of owning a pair of dense breasts, all you hear is crickets.

In a world where consumers are being forced to actively engage in the healthcare system and where women make the majority of household healthcare decisions, it is time for women to vote with their you-know-whats and demand that our lawmakers do the right thing. Failing to educate women to access proper breast cancer screening is no better than allowing men to continue receiving useless PSA exams when other screening methods would better achieve the intended outcome. All of us have been reading a whole lot about that in the paper (or on Google News) lately. Time to expand the discussion northward.  Once again, I urge you to check out AreYouDense.com and get informed. Next time you (or your loved one) gets a mammogram, make sure to ask the physician the question: do I have dense breast tissue?  Do not shut up until you know the answer and your options.

As for Wanda Sykes, she appears, at least on TV, to be as spunky as ever. She recently turned 47 and has written some incredibly funny comedy material on aging and health recently. One great bit is about doctors and how they are forced to “diagnose in fruit” since no one understands the metric system, which I’ll gift to you here.

httpv://www.youtube.com/watch?v=SU8506LwOaw

However, my favorite Sykes bit about growing older is this one about how much fun it is to be a middle-aged woman with a bladder. If this video doesn’t make you laugh til you have to run to the ladies’ room, something is wrong with you. I’m pretty sure men will find it hilarious too.

httpv://www.youtube.com/watch?v=tGOn9hWtBz8&feature=relmfu

Ps–thanks to my partner at Psilos, Dave Eichler, for his input to this post.