After the hurdles of FDA approval, insurance coverage, and reimbursement have been cleared, the adoption and dissemination of new breast cancer detection technologies will ultimately depend on whether women and their health care providers find them acceptable. Much is already known about the adoption and dissemination of screening mammography, and this knowledge may prove instructive for other developing technologies. Experience from current mammography programs suggests that outreach to women, education of women and providers, and access to facilities and services are all essential components of successful dissemination.
The use of screening mammography has increased greatly in the last decade, but a significant number of women still do not get screened, and many others do not undergo screening at the recommended intervals.
Women often express concerns about discomfort from the procedure, the inconvenience of scheduling an annual test, lack of access to screening facilities, and fear of what could be found (including false-positive results). Studies indicate that physician recommendation is the single most influential factor in determining whether women are screened.
Access to screening facilities may be particularly difficult for women who lack health insurance. The National Breast and Cervical Cancer Early Detection Program was established through the Centers for Disease Control and Prevention with the goal of providing screening examinations for uninsured women. The program has grown considerably since it was launched 10 years ago, but it still only reaches about 12 to 15 percent of eligible women nationwide. New federal legislation that would allow Medicaid coverage for treatment of breast cancer detected through the program was recently passed, but adoption of this program by the states is pending.
As more women adopt the practice of routine screening and the number of women eligible for screening mammography increases (because of the aging U.S. population), there will be increased demands for trained mammographers and certified screening facilities. There are anecdotal reports that inadequate numbers of mammographers and mammography technologists are being trained to fulfill current and future needs, but quantitative data to support these assertions are not available.
Concerns have also been expressed among radiologists and health care administrators that the reimbursement rate for mammography is too low to cover the procedure’s actual costs (including the costs of complying with federally mandated quality standards, which are unique to mammography) and that this situation could lead to a reduction in the availability of screening services. Quantitative data are unavailable to confirm or refute these concerns. If the rate of reimbursement for mammography truly is artificially low, then cost comparisons with new technologies may also unfairly favor mammography.
When mammography was introduced, it was a “void-filling” technology and thus had no competition during the dissemination process.
New technologies face a much different scenario. Evaluation will likely include comparison with mammography, and adoption of a new technology will require competition with other detection technologies that are currently available. A goal of new technologies is to provide additional choices for women and their physicians, allowing an individualized approach to screening and diagnosis depending on a woman’s specific needs and characteristics. At the same time, new technologies may add layers of complexity to the decision-making processes associated with screening and diagnosis, making it more challenging to establish practice guidelines and to define a standard of care.
Sharyl J. Nass, I. Craig Henderson, and Joyce C. Lashof
Committee on Technologies for the Early Detection of Breast Cancer
National Cancer Policy Board INSTITUTE OF MEDICINE and Division of Earth and Life Studies
NATIONAL RESEARCH COUNCIL