Abstract P5-04-08: Breast cancer screening using ultrasound increases recall, biopsy, and cancer detection rates
Authors: Staib James , Soonavala Rashna , Byfield Stacey Dacosta , Badal Kimberly , Catlett Kierstin , Maffey Liz , Kim Mi-Ok , Wimmer Kenneth , Shieh Yiwey , Esserman Laura J. 
Published: March 2023

Background: Ultrasound is often used as an adjunct to mammography for breast cancer (BC) screening. Usage of screening ultrasound (US) varies by state, likely due to differences in state-specific breast density notification laws and mandates requiring insurance coverage of supplemental screening for women at elevated risk of breast cancer. Screening US can increase cancer detection rates among women with dense breasts, but may increase recalls and benign biopsies. As more states adopt policies mandating insurance coverage for “medically necessary” breast cancer imaging, it is important to understand the impact to screening US utilization and subsequent service utilization. This analysis examines use of screening US by state as well as associated rates of recall, biopsy, and cancer detection.

Methods: We analyzed deidentified administrative claims. We included women aged 18-74 years with ≥1 claim for screening mammography in 2018. First claim was index date. Continuous enrollment was required in a commercial (COM) or Medicare Advantage (MA) plan from 1/2016 to index date (baseline period) and from index date to 6 months after (follow-up period). Recall, biopsy, and cancer detection rates were calculated for the follow-up period. Recall was defined as ≥1 claim for mammography, diagnostic ultrasound, or MRI in the follow-up period. We used CPT/HCPCS codes to identify procedures. Screening US was identified by CPT 76641 (complete) with modifier 50 (bilateral) or LT/RT (left/right). Using ICD codes, cancer detection was defined as ≥1 claim for DCIS or invasive BC. We examined screening US rates by insurance type, state, and age. Proportions were compared with chi-squared tests.

Results: 939,410 women met study criteria (70% COM, 30% MA; Tables 1-2). In the COM population, recall, biopsy, and cancer detection rates with screening US were approximately two-fold higher than without (recall: 26.1% vs. 11.8%; biopsy: 5.0% vs 1.6%; cancer detection: 1.0% vs. 0.4%). In the MA population, recall, biopsy, and cancer detection rates with screening US were roughly three-fold higher than without (recall: 23.6% vs 9.0%; biopsy: 5.2% vs 1.6%; cancer detection: 1.9% vs 0.7%). In NY, NJ, and CT, the rate of screening US usage was &gt; 14 times higher than in all other states (29.1% vs 1.9%). These three states had higher recall and biopsy rates, but similar cancer detection rates compared to all other states (recall: 14.4% vs. 11.4%; biopsy: 2.5% vs 1.7%; cancer detection: 0.6% vs. 0.5%). All proportion differences reached statistical significance (p &lt; 0.001).

Conclusion: Screening US was associated with increases in recall and biopsy, but modest increases in absolute cancer detection rates. Observed state by state variation of screening US is likely driven by laws requiring zero patient payment insurance coverage of “medically necessary” imaging which, as is the case with NY, NJ, and CT, is interpreted to include screening US. Our results demonstrate that screening US may lead to a large increase in recall rates and biopsies without consequentially improving the cancer detection rate.

Table 1: Recall, biopsy, and cancer detection rates by age with and without use of adjunctive breast screening ultrasound in a commercially insured U.S. population * values are suppressed to comply with requirements for data release

Table 2: Recall, biopsy, and cancer detection rates by age with and without use of adjunctive breast screening ultrasound in a Medicare Advantage (MA) U.S. population * values are suppressed to comply with requirements for data release

Citation Format: James Staib, Rashna Soonavala, Stacey Dacosta Byfield, Kimberly Badal, Kierstin Catlett, Liz Maffey, Mi-Ok Kim, Kenneth Wimmer, Yiwey Shieh, Laura J. Esserman. Breast cancer screening using ultrasound increases recall, biopsy, and cancer detection rates [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-04-08.