Statement of Dr. Diana Zuckerman, President
Cancer Prevention and Treatment Fund
Regarding Legislation to Require Warning Letters to Women with Dense Breasts
To Nevada Assembly, Committee on Health and Human Services
March 11, 2013
To: Assembly Committee on Health and Human Services
Re: Opposition to AB147- Statement of Dr. Diana Zuckerman, President, Cancer Prevention and Treatment Fund
Date: March 11, 2013
Among experts in women’s health and experts in breast cancer, there is considerable concern about Assembly Bill 147 and similar legislation in other states.
While we agree that women with dense breasts should discuss the implications of that health condition with their physician, we are concerned that women who receive required form letters are more frightened than informed. That has certainly been the experience in other states.
First, let’s examine the facts. The diagnosis of dense breasts is common and not life-threatening. It is one of several traits that will influence a woman’s risk of breast cancer, including the age at which she has children, how many months she spends breastfeeding, and whether she takes menopausal hormone therapy.
Dense breasts also increase a woman’s risk of having an inaccurate mammography report. However, for all women, mammography fails to detect a breast tumor approximately 30% of the time. That risk increases to approximately 50% of the time if the woman has breast implants. If mammography reports are going to warn women with dense breasts about breast cancer risk or risk of inaccurate mammography, perhaps they should also provide these additional warnings.
Now, let’s consider how that information is provided to women. Most women read their mammography reports in the evening or weekend, when they are home from work and have time to read their mail. If they receive a form letter that tells them they are at risk, without explaining exactly what the risk is, that can be confusing and frightening. They will then have to wait until they are able to talk to their doctor about it, which could be at least a few days, if not a few weeks.
Wouldn’t it be better for the patient to receive that information in a conversation with her doctor?
Finally, now that the woman has the information, what is she to do with it? If a mammogram says that a woman who has no lump or symptoms and no sign of cancer on her mammogram, should she have more screening tests anyway, just because her breasts are dense? Breast cancer experts are not in agreement about which additional tests are most helpful for which women under what circumstances, because data are lacking. However, in a situation where a woman is worried after reading a form letter with an explanation required by the state of Nevada, there is likely to be pressure on the doctor to prescribe additional testing, whether needed or not, if only because of fear of a law suit. That is exactly what happened in Connecticut, which passed a similar law. Physicians had to hire more staff to handle all the sonograms and other tests, adding to the cost of health care. Most of the tests did not change the diagnosis, and there is no evidence that these tests saved lives.
A screening mammography has many benefits, but it also has risks. It has a substantial rate of “false positives,” where women are told an abnormality has been found and additional testing is required, only to find days or weeks later that there was no health problem at all. Meanwhile, the stress and anxiety has taken a toll on the woman. Radiation from mammography and other screening tests can increase the risk of developing breast cancer over the years, so that is a very important risk. And, of course, the costs of these additional tests can be substantial.
For these reasons, conversations are preferable to form letters, which we believe are more frightening than informative. We would expect Nevada physicians to know the importance of having these conversations, but if there is a doubt about that, the Nevada legislature might want to pass a resolution or encourage the Health Department to conduct a public education campaign. Either would be preferable to a law requiring form language in mammography reports.