NATIONAL HARBOR, Md. -- The decision of whether to conduct additional breast cancer screening on women with dense breasts should be made between the patient and her physician, and insurers should pay for any extra imaging if recommended, American Medical Association (AMA) delegates agreed Monday.
Delegates approved parts of a resolution at their interim meeting here reaffirming existing AMA policy that supports screening mammography and opposes state laws requiring mandatory notification to patients if they are found to have dense breast tissue.
But disagreement came when Alan Klitzke, MD, of Buffalo, New York, a delegate for the American College of Nuclear Medicine but speaking for himself, suggested removing a sentence in the resolution asking the AMA to "encourage research on the benefits and harms of adjunctive screening for breast cancer for women identified to have dense breasts on an otherwise negative screening mammogram, in order to guide appropriate and evidence-based insurance coverage of the service."
"Dense breasts may or may not be considered one of those things that require additional imaging," said Klitzke. "This is an issue between the patient and her physician, and the problem we're trying to get to is that additional studies, when appropriate, should be reimbursed. Let's please stick to that."
Not so fast, responded Laura Faye Gephart, MD, speaking for the Texas delegation, who objected to the removal. "This [sentence] is asking for research on the benefits and harms of added screening for this population, because we don't have clear guidance as to what is not only going to catch cancer sooner, but improve survival, decrease morbidity, and decrease mortality. We encourage you to vote for this ... specifically because it asks for increased research so we can catch cancer sooner."
The delegates voted to keep the sentence but with added clarification: "evidence-based care and insurance coverage of the service."
"I don't know anything about evidence-based insurance coverage, but I sure know about evidence-based care," said Melissa Garretson, MD, of Fort Worth, Texas, an American Academy of Pediatrics delegate who was speaking for herself in suggesting the change.
The Texas delegation tried unsuccessfully to refer to the board of trustees a sentence in the resolution suggesting that the AMA "support insurance coverage for and adequate access to supplemental screening recommended for patients with 'dense breast' tissue following a discussion between the patient and their physician which integrates secondary risk characteristics."
"That is mandated benefit coverage, which this house has a history of opposing," said Gephart. "We allow women the freedom to choose their health insurance to balance a lower copay with more restricted benefits. Mandating coverage of benefits limits freedom."
"As a woman, a women's healthcare provider, and someone touched by cancer with the death of my grandmother 11 days ago, I deeply feel the emotion wrapped up in this issue," she added. "But referral with report back allows us to create the best policy for our AMA with regard to this emotional, complicated, and multidisciplinary issue."
Steven Chen, MD, chair of the reference committee that helped develop the resolution, said his committee "tried to work through the language to craft something we thought struck a balance here ... I would hope once a decision is made, this would be covered." Delegates agreed with Chen and voted to leave the sentence in.