Screening for Breast and Lung Cancers

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:07Welcome to Yale Cancer
00:07 --> 00:08Answers with your host
00:08 --> 00:11Doctor Anees Chagpar.
00:11 --> 00:13Yale Cancer Answers features the latest information on
00:13 --> 00:15cancer care by welcoming oncologists and
00:15 --> 00:18specialists who are on the forefront of
00:18 --> 00:20the battle to fight cancer. This week,
00:20 --> 00:21it's a conversation about screening for
00:21 --> 00:23breast and lung cancers with Doctor
00:23 --> 00:24Ilana Richman.
00:24 --> 00:26Dr Richman is an assistant
00:26 --> 00:27professor in internal medicine
00:27 --> 00:29at the Yale School of Medicine,
00:29 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:34 --> 00:35So Ilana,
00:35 --> 00:36maybe we can start off by you
00:36 --> 00:38telling us a little bit about
00:38 --> 00:40yourself and what it is you do.
00:40 --> 00:43I'm a general internist.
00:43 --> 00:46I see patients in primary care.
00:46 --> 00:49And it was actually my clinical
00:49 --> 00:50practice as a general internist
00:50 --> 00:53that led me to get interested in
00:53 --> 00:55prevention and cancer screening.
00:55 --> 00:56It's kind of a core part of what
00:56 --> 00:58we do in primary care is to try
00:58 --> 01:00to keep our patients healthy.
01:00 --> 01:01It's part of what drew me to
01:01 --> 01:03primary care in the 1st place,
01:03 --> 01:05and also what has led to my research
01:05 --> 01:07interests in cancer screening
01:08 --> 01:10so so tell us a little bit more
01:10 --> 01:12about that so you know one of the
01:12 --> 01:14things that I think our listeners
01:14 --> 01:16will be very familiar with is the.
01:16 --> 01:20Fact that you know there are so many cancers,
01:20 --> 01:22some of which you can screen for
01:22 --> 01:24some of which you can't screen for.
01:24 --> 01:26And even the ones that you can
01:26 --> 01:28screen for it seems like the
01:28 --> 01:30screening guidelines keep changing.
01:30 --> 01:33So how do you approach screening from
01:33 --> 01:36a primary care kind of standpoint?
01:37 --> 01:40So those are great questions.
01:40 --> 01:42I'll start with the first,
01:42 --> 01:44which is why is it that some cancers
01:44 --> 01:47we can screen for and others we can't?
01:47 --> 01:49The answer to that really has to do with
01:49 --> 01:51lots of different aspects of what it means
01:51 --> 01:54to have a successful screening test in
01:54 --> 01:56order for screening to be successful,
01:56 --> 01:59we need to be able to reliably detect
01:59 --> 02:02a cancer we need to be able to find
02:02 --> 02:04it at a point when it's treatable and
02:04 --> 02:06we need to have good treatments for
02:06 --> 02:08that disease. So there are a few.
02:08 --> 02:11Cancer is that fit that profile.
02:11 --> 02:12The ones that we commonly screened
02:12 --> 02:14for are good examples, breast cancer,
02:14 --> 02:17colorectal cancer, cervical cancer, and more.
02:17 --> 02:18Recently lung cancer.
02:18 --> 02:20But there are many others that don't.
02:20 --> 02:22For a variety of reasons,
02:22 --> 02:23it's sort of too hard to find them.
02:23 --> 02:25The cancers generally tend to be aggressive,
02:25 --> 02:27and so screening once a year actually
02:27 --> 02:30wouldn't even be enough or we don't have
02:30 --> 02:32good treatments even for early stage disease.
02:32 --> 02:34The last piece I'll say is that
02:34 --> 02:36cancers need to be common enough,
02:36 --> 02:39or or you need to identify a high enough
02:39 --> 02:41risk population to make screening worthwhile.
02:42 --> 02:43So there may be some cancers,
02:43 --> 02:44for example that are quite rare and
02:44 --> 02:46we would just never consider screening
02:46 --> 02:48every patient who comes along with them,
02:48 --> 02:49because just makes no sense to
02:49 --> 02:50go looking for attention.
02:50 --> 02:52It's extremely unlikely to be there,
02:52 --> 02:55so those are some of the features that
02:55 --> 02:59make screening reasonable to think
02:59 --> 03:03about in terms of why guidelines change.
03:03 --> 03:06It's a great question and tends to
03:06 --> 03:09have to do with. A couple things.
03:09 --> 03:12First is sometimes the evidence changes,
03:12 --> 03:15so lung cancer screening is a great example.
03:15 --> 03:17For years and years we had no effective
03:17 --> 03:19way to screen for lung cancer.
03:19 --> 03:21Lots of approaches to lung cancer
03:21 --> 03:23screening were studied, so for example,
03:23 --> 03:26can we take a test X ray of people
03:26 --> 03:28who smoke cigarettes every year
03:28 --> 03:29and look for lung cancer?
03:29 --> 03:31Can we examine the sputum that
03:31 --> 03:33kind of phlegm that people cough up
03:33 --> 03:34and look for signs of cancer?
03:34 --> 03:36Those approaches were studied and were
03:36 --> 03:38not successful, and so for a long time.
03:38 --> 03:40The recommendation was not to screen
03:40 --> 03:43using any of those modalities,
03:43 --> 03:44but.
03:44 --> 03:45In 2011,
03:45 --> 03:47a landmark study was published
03:47 --> 03:50that showed that we can effectively
03:50 --> 03:51use computed tomography,
03:51 --> 03:52which is CT scan the kind of test
03:53 --> 03:54where you lie down on a table and
03:54 --> 03:56get zipped through a donut takes a
03:56 --> 03:57very detailed picture of your chest.
03:57 --> 04:00We can use that to look for early
04:00 --> 04:02signs of lung cancer among people who
04:02 --> 04:04are high risk for developing lung cancer,
04:04 --> 04:06and in fact it works if we use it
04:06 --> 04:08annually for a number of years.
04:08 --> 04:11We tend to find lung cancers early
04:11 --> 04:12when they're treatable.
04:12 --> 04:16And we can actually successfully avert.
04:16 --> 04:18You know the risk of dying of
04:18 --> 04:19lung cancer for some people.
04:19 --> 04:21So in 2013 our recommendations
04:21 --> 04:24changed and slowly this technology
04:24 --> 04:26has percolated out into the community,
04:26 --> 04:30so sometimes recommendations change
04:30 --> 04:32in response to our scientific
04:32 --> 04:35understanding of what works.
04:35 --> 04:38And then lastly, I'll say that
04:38 --> 04:40sometimes recommendations change
04:40 --> 04:43because population health changes.
04:43 --> 04:44Colorectal cancer screening
04:44 --> 04:46is a good example of that.
04:46 --> 04:48We are using the same technologies
04:48 --> 04:49that we've used for collecting
04:49 --> 04:51cancer screening more or less
04:51 --> 04:53for the last 10 or 20 years,
04:53 --> 04:55or maybe even longer.
04:55 --> 04:57We use colonoscopy which is a test
04:57 --> 05:00where we use a camera to directly
05:00 --> 05:02look for early signs of colon cancer,
05:02 --> 05:04or we can use stool based test.
05:04 --> 05:06Sorry, look in the stool for signs of cancer,
05:06 --> 05:08but more recently we've understood
05:08 --> 05:10that actually the epidemiology
05:10 --> 05:12of colon cancer is changing.
05:12 --> 05:14Colon cancer seems to be more
05:14 --> 05:15common among younger adults,
05:15 --> 05:17and so we've actually lowered the
05:17 --> 05:19age at which we recommend colon
05:19 --> 05:21cancer screening for for adults.
05:21 --> 05:22So we used to say start at age
05:22 --> 05:2450 for average risk adults and
05:24 --> 05:26now we say start at age 45,
05:26 --> 05:27and that's in response.
05:27 --> 05:29Not to some new scientific understanding
05:29 --> 05:30about colon cancer screening,
05:30 --> 05:31but in response to changes in the
05:31 --> 05:33epidemiology of the disease itself,
05:33 --> 05:35so lots of reasons why
05:35 --> 05:36recommendations might change.
05:37 --> 05:40And then there are some diseases where
05:40 --> 05:42you know it depends on who you ask,
05:42 --> 05:45what the recommendations are and
05:45 --> 05:47and breast cancer seems to be
05:47 --> 05:49one that falls into that bucket.
05:49 --> 05:51Can you talk a little bit about that?
05:51 --> 05:54Because I think that that actually causes a
05:54 --> 05:57lot of confusion amongst the general public.
05:57 --> 06:00If they look at, for example,
06:00 --> 06:02the American Cancer Society guidelines,
06:02 --> 06:05they may be different from the US
06:05 --> 06:07Preventive Services Task Force.
06:07 --> 06:09From the American College of
06:09 --> 06:12Radiology from the American College
06:12 --> 06:14of Obstetrics and Gynecology.
06:14 --> 06:18So how do you kind of approach that?
06:18 --> 06:20Why are there differences,
06:20 --> 06:22and how can you help our listeners
06:22 --> 06:24to figure out which guidelines
06:24 --> 06:26they should be following?
06:27 --> 06:29I'll give you an example for
06:29 --> 06:30listeners that may not, you know,
06:30 --> 06:32know some of the nuances around these
06:32 --> 06:33guys 'cause they think it's helpful
06:33 --> 06:35to talk about some of the specifics
06:35 --> 06:36and give a sense of how the guidelines
06:36 --> 06:38might differ in primary care.
06:38 --> 06:39We often rely on guidelines put
06:39 --> 06:41out by a group called the US
06:41 --> 06:43Preventive Services Task Force,
06:43 --> 06:45which is a volunteer organization
06:45 --> 06:47of experts in medicine and public
06:47 --> 06:49health and that group, for example,
06:49 --> 06:52has recommended that for women in their 40s.
06:52 --> 06:53Women can consider getting screened
06:53 --> 06:56for breast cancer every other year,
06:56 --> 06:57and that should be a discussion with
06:57 --> 06:59their physician or their clinician about
06:59 --> 07:01the risks and benefits of screening.
07:01 --> 07:03But it's not sort of a strong
07:03 --> 07:04recommendation that women should
07:04 --> 07:06definitely get screened beginning
07:06 --> 07:09in the 50s between age 50 and 74.
07:09 --> 07:10There's a stronger recommendation that
07:10 --> 07:12women should be screened every other year.
07:12 --> 07:13In contrast,
07:13 --> 07:16the American Cancer Society guidelines say
07:16 --> 07:19women 40 to 44 can consider screening,
07:19 --> 07:21but beginning at 45 age 45.
07:21 --> 07:24Up to 55 women in that age group should
07:24 --> 07:26actually consider annual screening,
07:26 --> 07:28which is quite different than
07:28 --> 07:30saying maybe women 45 to 50 should
07:30 --> 07:32be screened every other year.
07:32 --> 07:34So why would accounts for the difference?
07:34 --> 07:36I would say it's sort of a different
07:36 --> 07:38approach to balancing benefit and
07:38 --> 07:40harm the US Preventive Services
07:40 --> 07:41Task Force looked at the guidelines
07:41 --> 07:43and say you know what?
07:43 --> 07:44In general women in their 40s are at
07:44 --> 07:46low risk for developing breast cancer,
07:46 --> 07:48and if we screen them in this population.
07:48 --> 07:50There's some incremental benefits.
07:50 --> 07:53A small number of women will have
07:53 --> 07:55a late stage breast cancer,
07:55 --> 07:55breast cancer,
07:55 --> 07:56death averted,
07:56 --> 07:58but many many more women will have
07:58 --> 07:59a false positive test.
07:59 --> 08:02They'll be some abnormality seen
08:02 --> 08:02on their mammogram.
08:02 --> 08:04That turns out to be nothing but
08:04 --> 08:06that woman is then put through
08:06 --> 08:07this experience of being told
08:07 --> 08:09that the mammogram is abnormal.
08:09 --> 08:10You might need additional imaging.
08:10 --> 08:12You might need a biopsy and you now
08:12 --> 08:14go through a few weeks where you
08:14 --> 08:17are worried that you might have a
08:17 --> 08:18breast cancer and that experiences.
08:18 --> 08:21Unpleasant to to put it mildly so you know,
08:21 --> 08:24I think it's sort of the way that two
08:24 --> 08:27people can look at the same situation
08:27 --> 08:28and see it slightly differently.
08:28 --> 08:31Different groups look at the same data,
08:31 --> 08:33and for some for some guideline
08:33 --> 08:34organizations they say hey,
08:34 --> 08:36our number one goal is to avert
08:36 --> 08:38breast cancer deaths and others
08:38 --> 08:40say we need to balance that with
08:40 --> 08:42the very real kind of burdens and
08:42 --> 08:44harms that come from screenings.
08:44 --> 08:45I think it's really,
08:45 --> 08:47you know how organizations.
08:47 --> 08:52Decide where the net benefit lies.
08:52 --> 08:53Getting back to patients,
08:53 --> 08:54I would say you know,
08:54 --> 08:58for women in their 40s and.
08:58 --> 09:00It's an opportunity to think
09:00 --> 09:01about what matters.
09:01 --> 09:02Some women,
09:02 --> 09:03I think in that age group would say,
09:03 --> 09:03hey,
09:03 --> 09:05you know I have seen other women go
09:05 --> 09:07through the experience of breast cancer,
09:07 --> 09:09and I never want to.
09:09 --> 09:11I never want to deal with a late
09:11 --> 09:13stage breast cancer and I would like
09:13 --> 09:15to do everything I can to avoid that.
09:15 --> 09:17And for those women, I think it for sure.
09:17 --> 09:19Makes sense to be screened.
09:19 --> 09:20Other women may have personal risk factors
09:20 --> 09:22that make it sensible to be screened.
09:22 --> 09:24You know, close relatives first,
09:24 --> 09:26you know mother or sisters who've
09:26 --> 09:28had breast cancer and their
09:28 --> 09:30personal risk is higher and they
09:30 --> 09:32may feel compelled to be screened.
09:32 --> 09:33You know other women might look
09:33 --> 09:34at the same situation and say,
09:34 --> 09:36you know what I feel healthy.
09:36 --> 09:37I don't have any specific risk
09:37 --> 09:39factors and for me it makes sense
09:39 --> 09:41to minimize the number of tests that
09:41 --> 09:42you know I have to go through and
09:42 --> 09:44I'll I'll start screen when I'm 50.
09:44 --> 09:45And that's also, I think,
09:45 --> 09:46a reasonable decision.
09:47 --> 09:49And so you know, it sounds like
09:49 --> 09:51women should really think about
09:51 --> 09:54what what is their personal risk,
09:54 --> 09:55what's important to them,
09:55 --> 09:57and talk to their doctor.
09:57 --> 10:00How does this intersect with?
10:00 --> 10:03You know, insurance companies and
10:03 --> 10:07governments who have to pay for these tests.
10:07 --> 10:11I mean, many plans would
10:11 --> 10:13cover preventative services.
10:13 --> 10:16But do they cover them?
10:16 --> 10:18Kind of based on one set of
10:18 --> 10:19guidelines versus another.
10:19 --> 10:20So for example,
10:20 --> 10:23if you are a 40 year old and you
10:23 --> 10:26decide I want to get a mammogram every
10:26 --> 10:27year because that's important to me,
10:27 --> 10:30I've had close friends who have
10:30 --> 10:31gone through the experience.
10:31 --> 10:34I never want to go through that,
10:34 --> 10:36even if I don't necessarily have
10:36 --> 10:39a personal family history myself,
10:39 --> 10:41or am necessarily at high risk,
10:41 --> 10:43but that fits.
10:43 --> 10:45Within some society guidelines
10:45 --> 10:47but not within others,
10:47 --> 10:49is that still covered by insurance?
10:49 --> 10:51The history of insurance coverage of
10:51 --> 10:53screening is actually really interesting
10:53 --> 10:55and I can tell you a little bit about
10:55 --> 10:57kind of the back story for context and
10:57 --> 11:01then we can talk about current policies.
11:01 --> 11:03Actually, you know when Medicare
11:03 --> 11:05was first signed into law in 1965?
11:05 --> 11:08Amazingly, Medicare didn't cover any
11:08 --> 11:11preventive services at all because it was
11:11 --> 11:14intended as a program to cover medical care
11:14 --> 11:17for the treatment and diagnosis of disease.
11:17 --> 11:18So prevention actually
11:18 --> 11:19doesn't fall into that right?
11:19 --> 11:21We're talking about healthy people.
11:21 --> 11:23But over the next few decades,
11:23 --> 11:26it became clear that things like vaccination,
11:26 --> 11:28cancer screening have benefit to
11:28 --> 11:31individuals and to the population health,
11:31 --> 11:32and these are really things that
11:32 --> 11:33ought to be covered under insurance.
11:33 --> 11:36So beginning in the late 80s and early 90s,
11:36 --> 11:37Medicare began to cover,
11:37 --> 11:38for example,
11:38 --> 11:40cervical cancer screening and
11:40 --> 11:41breast cancer screening,
11:41 --> 11:44and then in 2003 there was a larger sort
11:44 --> 11:47of more systematic update to Medicare that
11:47 --> 11:50generalized coverage for preventive services.
11:50 --> 11:51The next.
11:51 --> 11:51Iteration,
11:51 --> 11:55the big next big change came in
11:55 --> 11:562010 with the Affordable Care Act
11:56 --> 11:58and the Affordable Care Act made
11:58 --> 12:00important revisions or amendments.
12:00 --> 12:03The way that preventive services are covered,
12:03 --> 12:05the Affordable Care Act took the
12:05 --> 12:07step of linking insurance coverage
12:07 --> 12:10to evidence based recommendations.
12:10 --> 12:13They said that for private insurers,
12:13 --> 12:15those private insurers have
12:15 --> 12:16to cover preventive services,
12:16 --> 12:17including cancer screenings that
12:17 --> 12:21are given a top rating by the US
12:21 --> 12:22Preventive Services Task Force.
12:22 --> 12:23That's that committee.
12:23 --> 12:25That I mentioned that's composed of
12:25 --> 12:27doctors and public health experts
12:27 --> 12:29that evaluate the evidence in
12:29 --> 12:31the data around cancer screening
12:31 --> 12:32and other preventive services.
12:32 --> 12:34And if that group gives it its,
12:34 --> 12:35you know,
12:35 --> 12:37one of its strongest two ratings insurance
12:37 --> 12:39companies have to cover that service,
12:39 --> 12:40and they have to cover
12:40 --> 12:40it without cost sharing,
12:41 --> 12:42which means that they can't charge
12:42 --> 12:44an out of pocket component.
12:44 --> 12:48No deductible or copay or coinsurance,
12:48 --> 12:49so that was a step forward.
12:49 --> 12:50Now interestingly,
12:50 --> 12:52breast cancer screening for women
12:52 --> 12:55in their 40s is given AC rating.
12:55 --> 12:58By the US Preventive Services Task Force,
12:58 --> 13:00which means that there's some evidence
13:00 --> 13:03for small benefit, but it's not.
13:03 --> 13:05It's strongest A or B rating.
13:05 --> 13:07So under the Affordable Care Act.
13:09 --> 13:12Under the Affordable Care Act.
13:12 --> 13:14Insurance companies would
13:14 --> 13:16not be required to cover.
13:18 --> 13:19Breast cancer screening for
13:19 --> 13:21women in their 40s, however,
13:21 --> 13:22there was a separate statute
13:22 --> 13:24signed into law that requires
13:24 --> 13:26coverage for women in their 40s.
13:26 --> 13:27There's kind of a carve
13:27 --> 13:28out legislation that said,
13:28 --> 13:29we think it's important that
13:29 --> 13:30women in the 40s have access
13:30 --> 13:31to breast cancer screening,
13:31 --> 13:32so it's generally covered
13:32 --> 13:34by most private insurers.
13:34 --> 13:37I will say that the Affordable Care
13:37 --> 13:39Act doesn't apply to every insurer,
13:39 --> 13:40and it actually doesn't apply
13:40 --> 13:41to Medicare and Medicaid,
13:41 --> 13:43although those programs generally
13:43 --> 13:46cover breast cancer screening without
13:46 --> 13:48cost because of other legislation.
13:48 --> 13:49So it's always important to
13:49 --> 13:50check with your insurance,
13:50 --> 13:51'cause there's all kinds of
13:51 --> 13:52asterisks and exceptions,
13:52 --> 13:55but I think for most women with
13:55 --> 13:57private insurance with Medicare and
13:57 --> 13:58Medicaid breast cancer screening,
13:58 --> 13:59even for women in their 40s
13:59 --> 14:00is generally covered
14:01 --> 14:03We're going to pick up
14:03 --> 14:05this conversation right after we take
14:05 --> 14:07a short break for a medical minute.
14:07 --> 14:09Please stay tuned to learn more
14:09 --> 14:11about screening for breast and
14:11 --> 14:12lung cancers with my guest
14:12 --> 14:13Dr. Ilana Richman.
14:14 --> 14:16Funding for Yale Cancer Answers
14:16 --> 14:18comes from Smilow Cancer Hospital
14:18 --> 14:20where the breast cancer Prevention
14:20 --> 14:22Clinic provides comprehensive risk
14:22 --> 14:24assessment education and screening for
14:24 --> 14:26women at increased risk of breast cancer.
14:26 --> 14:30To learn more, visit Yale
14:30 --> 14:32Cancer Center org genetics.
14:32 --> 14:34Genetic testing can be useful for
14:34 --> 14:36people with certain types of cancer
14:36 --> 14:38that seem to run in their families.
14:38 --> 14:40Genetic counseling is a process that
14:40 --> 14:42includes collecting a detailed personal
14:42 --> 14:45and family history or risk assessment and
14:45 --> 14:48a discussion of genetic testing options.
14:48 --> 14:50Only about 5 to 10% of all
14:50 --> 14:51cancers are inherited,
14:51 --> 14:53and genetic testing is not
14:53 --> 14:54recommended for everyone.
14:54 --> 14:57Individuals who have a personal and
14:57 --> 14:59or family history that includes
14:59 --> 15:01cancer at unusually early ages.
15:01 --> 15:03Multiple relatives on the same side
15:03 --> 15:05of the family with the same cancer.
15:05 --> 15:08More than one diagnosis of cancer
15:08 --> 15:09in the same individual,
15:09 --> 15:12rare cancers or family history of a
15:12 --> 15:14known altered cancer predisposing gene
15:14 --> 15:17could be candidates for genetic testing.
15:17 --> 15:19Resources for genetic counseling and
15:19 --> 15:21testing are available at federally
15:21 --> 15:23designated comprehensive cancer
15:23 --> 15:25centers such as Yale Cancer Center
15:25 --> 15:27and Smilow Cancer Hospital.
15:27 --> 15:30More information is available at
15:30 --> 15:31yalecancercenter.org. You're listening
15:31 --> 15:33to Connecticut Public Radio.
15:34 --> 15:36Welcome back to Yale Cancer Answers.
15:36 --> 15:39This is doctor Anees Chagpar and I'm joined
15:39 --> 15:42tonight by my guest Doctor Ilana Richman.
15:42 --> 15:44We're learning about screening for
15:44 --> 15:46breast and lung cancers and Alana.
15:46 --> 15:49You left off right before the break
15:49 --> 15:52talking about the Affordable Care Act
15:52 --> 15:55and the fact that it mandated that
15:55 --> 15:58for people with private insurance,
15:58 --> 16:01those insurers have to cover
16:01 --> 16:04screening for cancer.
16:04 --> 16:10That has reached the level of evidence
16:10 --> 16:14based recommendations from the USPSTF.
16:14 --> 16:16But you also made one comment
16:16 --> 16:18which I wanted to go back to,
16:18 --> 16:22which was there's a lot of asterisks
16:22 --> 16:25and it's most private insurers tell
16:25 --> 16:26us a little bit more about that.
16:26 --> 16:29I mean, how do you know if you
16:29 --> 16:32are in the most private insurers,
16:32 --> 16:34or whether there's a carve out
16:34 --> 16:37which might leave you with a bill?
16:37 --> 16:40So the insurers that are covered
16:40 --> 16:42under the Affordable Care Act don't
16:42 --> 16:44include firms that are self insured,
16:44 --> 16:47so lots of large companies actually don't
16:47 --> 16:49pay for traditional health insurance.
16:49 --> 16:51What they do is set aside money to directly,
16:51 --> 16:53essentially directly pay for the
16:53 --> 16:55health care of their employees,
16:55 --> 16:57which is not considered traditional
16:57 --> 16:59insurance and not is not covered under
16:59 --> 17:01statutes like the Affordable Care Act.
17:01 --> 17:02On the other hand,
17:02 --> 17:04lots of those companies that do that
17:04 --> 17:07still conform to the general kinds of
17:07 --> 17:10coverage that other large insurers offer,
17:10 --> 17:12so that's why I say it's important to
17:12 --> 17:14check with your insurance company just
17:14 --> 17:16to make sure you won't be surprised.
17:16 --> 17:17Unpleasantly surprised if you
17:17 --> 17:19end up with a bill.
17:19 --> 17:21I don't think there's one other
17:21 --> 17:24asterisk to be aware of, which is that.
17:24 --> 17:26Not all kinds of breast cancer
17:26 --> 17:28screening are covered equally,
17:28 --> 17:30so for example.
17:30 --> 17:33Most insurance as we talked about
17:33 --> 17:35covers breast cancer screening,
17:35 --> 17:38but that's sort of narrowly interpreted
17:38 --> 17:41to mean traditional digital mammography.
17:41 --> 17:43Other newer technologies like
17:43 --> 17:443 dimensional mammography,
17:44 --> 17:47also known as digital breast tomosynthesis.
17:47 --> 17:50Or add on tests like ultrasound
17:50 --> 17:52or MRI may not be covered.
17:52 --> 17:55So if if those tests are recommended
17:55 --> 17:58or considered again it could be
17:58 --> 17:59important to ask whether they're
17:59 --> 18:01covered or whether you might be
18:01 --> 18:02responsible for share of the cost.
18:03 --> 18:05You know that's really interesting,
18:05 --> 18:07because I think that there are a lot
18:07 --> 18:09of women who go for their mammogram.
18:09 --> 18:12It just so happens that the place where I
18:12 --> 18:14get my mammogram only has tomosynthesis,
18:14 --> 18:18but what you're saying is that?
18:18 --> 18:21That might not be covered.
18:21 --> 18:23It depends on the state you live.
18:23 --> 18:25Some seats actually have
18:25 --> 18:27additional protections to ensure
18:27 --> 18:29that that service is covered.
18:29 --> 18:31Including the state of Connecticut,
18:31 --> 18:32but not all do.
18:32 --> 18:34So again, it's important to, I think,
18:34 --> 18:37ask what you might be responsible for,
18:37 --> 18:38and then even if you were to receive
18:38 --> 18:40one of those additional tests,
18:40 --> 18:41it might be that you're only
18:41 --> 18:42responsible for a portion of
18:42 --> 18:42it and not the whole thing.
18:42 --> 18:44But yes, you're right, women.
18:44 --> 18:46I think often don't always go into the test,
18:46 --> 18:47know exactly what they're going to get,
18:47 --> 18:49and it's pretty tough to be in the
18:49 --> 18:51moment and and concerned about.
18:51 --> 18:53You know whether or not you're going to
18:53 --> 18:55have a bill for what's what tests you get.
18:56 --> 18:59Is there any legal mandate for.
18:59 --> 19:03A you know a facility to tell you hey,
19:03 --> 19:07you know we are going to do a 3D mammogram,
19:07 --> 19:10and oh, by the way, that isn't
19:10 --> 19:12covered in this particular state.
19:13 --> 19:15I don't know that there's a
19:15 --> 19:17regulation of around disclosure.
19:17 --> 19:19Most facilities will have you agree
19:19 --> 19:22to pay if you're if there's a
19:22 --> 19:24component that you're liable for,
19:24 --> 19:25but I don't know if they're required
19:25 --> 19:27to disclose the cost upfront.
19:27 --> 19:30Yeah, that's really great information,
19:30 --> 19:32because it really does then
19:32 --> 19:35behoove people to ask you think?
19:35 --> 19:36I know that my insurance
19:36 --> 19:37coverage preventative care.
19:37 --> 19:39I know that they'll cover a mammogram,
19:39 --> 19:41but they may not cover it.
19:41 --> 19:44The mammogram that that particular?
19:44 --> 19:47A facility is offering in some states,
19:47 --> 19:49but it's good to know that
19:49 --> 19:51Connecticut does cover it.
19:51 --> 19:54The other thing that was interesting is
19:54 --> 19:57that it may not cover the accessory tests,
19:57 --> 19:59so you get a mammogram.
19:59 --> 20:01The mammogram sees something,
20:01 --> 20:04and your doctor says, well,
20:04 --> 20:06we need to look at that more
20:06 --> 20:07closely with an ultrasound,
20:07 --> 20:09or you've got dense breast tissue.
20:09 --> 20:12So we need to add on.
20:12 --> 20:13Ultrasound,
20:13 --> 20:16or maybe you've got a genetic
20:16 --> 20:19predisposition and your doctor says,
20:19 --> 20:19well,
20:19 --> 20:21you know you really need to
20:21 --> 20:23be screened with MRI,
20:23 --> 20:26but those tests may not be covered either.
20:27 --> 20:28That's right, or they may be covered in
20:28 --> 20:30part and you might have in it, you know,
20:30 --> 20:33copay or it might be part of your deductible,
20:33 --> 20:35at least under the Affordable Care Act.
20:35 --> 20:37None of those scenarios are
20:37 --> 20:38covered under the recommendations
20:38 --> 20:40that require coverage in full,
20:40 --> 20:42so those are outside of of what
20:42 --> 20:43the Affordable Care Act requires.
20:43 --> 20:45Now lots of insurance companies.
20:45 --> 20:46I would say OK,
20:46 --> 20:47those are medically necessary tests
20:47 --> 20:49and would cover them the way that they
20:49 --> 20:51would cover lots of other medical care.
20:51 --> 20:52But at least in terms of
20:52 --> 20:53the Affordable Care Act,
20:53 --> 20:56those are outside of the kind of narrow
20:56 --> 20:57recommendations around preventive
20:57 --> 20:58services and so are not required
20:58 --> 21:01to be covered under that statute.
21:01 --> 21:03The other thing is when we when
21:03 --> 21:05we're talking about lung cancer,
21:05 --> 21:08is well, can you kind of go over,
21:08 --> 21:12you know, the groups of people
21:12 --> 21:14who should get low dose CT scans.
21:14 --> 21:16I at the top of the show you
21:16 --> 21:18were kind of mentioning that.
21:18 --> 21:19For many years,
21:19 --> 21:21we really didn't have screening tests,
21:21 --> 21:26but now with low dose that is something that
21:26 --> 21:29is covered for for lung cancer screening,
21:29 --> 21:31but it's only covered
21:31 --> 21:32for certain populations.
21:32 --> 21:33Is that right?
21:33 --> 21:35Can you tell us who
21:35 --> 21:36benefits from a low dose CT
21:37 --> 21:40so low dose CT has been studied in high
21:40 --> 21:42risk populations and what's meant by
21:42 --> 21:45high risk is older adults who have a
21:45 --> 21:47substantial history of tobacco use.
21:47 --> 21:50Tobacco use is, of course the number one.
21:50 --> 21:53Risk factor for developing lung cancer.
21:53 --> 21:54Not all people who develop lung
21:54 --> 21:56cancer have a history of tobacco use,
21:56 --> 21:58but it is the strongest risk factor
21:58 --> 22:00serving the general population.
22:00 --> 22:03The most common risk factor we recommend
22:03 --> 22:05lung cancer screening for adults who are
22:05 --> 22:08between the ages of 50 and 80 who have
22:08 --> 22:11used tobacco within the past 15 years.
22:11 --> 22:14So either our current smokers or who
22:14 --> 22:16quit within the last 15 years and
22:16 --> 22:18who have a substantial tobacco use
22:18 --> 22:20history and by substantial I mean.
22:21 --> 22:23Have smoked at least a pack a day
22:23 --> 22:25or an equivalent for 20 years.
22:25 --> 22:27So that might mean so by equivalent.
22:27 --> 22:28An example would be if you smoked
22:28 --> 22:30half a pack a day for 40 years
22:30 --> 22:32or one pack a day for 20 years.
22:32 --> 22:35If you you know smoked a quarter
22:35 --> 22:38of a pack a day 40 years ago,
22:38 --> 22:41you would not have enough of a tobacco use
22:41 --> 22:43history to warrant lung cancer screening,
22:43 --> 22:45but for people who fit those criteria,
22:45 --> 22:47we think there's a substantial benefit
22:47 --> 22:50to being screened and people you know
22:50 --> 22:52would enter screening whenever there.
22:52 --> 22:54Identified as being eligible and the
22:54 --> 22:57idea is to continue to screen actually
22:57 --> 23:00annually every year with a chest CT
23:00 --> 23:03until one of several things happen,
23:03 --> 23:05either age out or it's been more
23:05 --> 23:07than 15 years since you quit smoking,
23:07 --> 23:09or you know you're diagnosed at
23:09 --> 23:10the lung cancer,
23:10 --> 23:11which hopefully would not happen.
23:11 --> 23:14But of course does from time to time,
23:14 --> 23:16so people who meet any of those criteria
23:16 --> 23:17could be considered for lung cancer.
23:17 --> 23:19Screening would continue annual screening
23:19 --> 23:21until one of those stopping points is met.
23:21 --> 23:23One of the questions that people might.
23:23 --> 23:26Be thinking about is how did they
23:26 --> 23:29come up with these guidelines?
23:29 --> 23:30Because you can understand that
23:30 --> 23:33you know the longer you smoke,
23:33 --> 23:34the higher your risk.
23:34 --> 23:37If you quit smoking many many years ago,
23:37 --> 23:42the lower your risk, the older you are.
23:42 --> 23:44Perhaps your increased risk,
23:44 --> 23:47but there's always some nuances so
23:47 --> 23:50you know people might be saying.
23:50 --> 23:53Well, an 80 year old who quit smoking
23:53 --> 23:5614 years ago and and smoked 20
23:56 --> 23:59pack years prior to that is covered
23:59 --> 24:02for a low dose CT even though
24:02 --> 24:05his life expectancy is fairly low
24:05 --> 24:07and his risk might be moderate,
24:07 --> 24:11whereas a 45 year old who might
24:11 --> 24:12have been smoking.
24:12 --> 24:16You know, since he was 10 or 15.
24:16 --> 24:20So say a 30 pack year history.
24:20 --> 24:23Is not covered because he's not old enough,
24:23 --> 24:25even though he's a current smoker.
24:25 --> 24:29So how do you kind of explain that to people?
24:29 --> 24:31The guidelines are really based
24:31 --> 24:33on two sets of information.
24:33 --> 24:35One is the clinical trials that
24:35 --> 24:37have been done, and then it's
24:37 --> 24:39probably our kind of gold standard.
24:39 --> 24:41Go to and they have really
24:41 --> 24:42been two clinical trials,
24:42 --> 24:44one done in the United States,
24:44 --> 24:45one in Europe.
24:45 --> 24:48They had slightly different entry
24:48 --> 24:51criteria and use slightly different
24:51 --> 24:53methods for detecting lung cancer,
24:53 --> 24:55but we try to match.
24:55 --> 24:58The population that we recommend lung
24:58 --> 25:01cancer screening for to those trials
25:01 --> 25:04because if we deviate you know much from
25:04 --> 25:06that then we really don't understand.
25:06 --> 25:08You know if we start recommending lung
25:08 --> 25:11cancer to people in their early 40s or 30s.
25:11 --> 25:12How you know how would those
25:12 --> 25:14populations have fared if we were
25:14 --> 25:15to actually study them in a trial?
25:15 --> 25:18They're sort of too far away from the data.
25:18 --> 25:21We have the 2nd way that recommendations
25:21 --> 25:24are made is through modeling,
25:24 --> 25:26and modeling is a approach
25:26 --> 25:29where we can actually simulate.
25:29 --> 25:30Using computer models,
25:30 --> 25:32the progression of cancer in kind
25:32 --> 25:34of a hypothetical or theoretical
25:34 --> 25:36population of patients and ask OK if
25:36 --> 25:38we screen people at these intervals
25:38 --> 25:39or these age ranges, what happens?
25:39 --> 25:41And so that's in part how some
25:41 --> 25:43of these decisions were made,
25:43 --> 25:44particularly around the upper
25:44 --> 25:46end of the age limit.
25:46 --> 25:48The child is didn't actually enroll people,
25:48 --> 25:50or at least the US trial didn't
25:50 --> 25:51actually enroll people in their 80s.
25:51 --> 25:54But modeling studies showed that.
25:54 --> 25:57Because lung cancer tends to be an
25:57 --> 25:59aggressive disease even among older
25:59 --> 26:01adults who naturally have a shorter
26:01 --> 26:02life expectancy due to their age,
26:02 --> 26:04there's still potential benefit even
26:04 --> 26:07you know, screen in the late 70s.
26:07 --> 26:09So that's how some of those
26:09 --> 26:11age ranges are established.
26:11 --> 26:14There's always some trade off,
26:14 --> 26:16so you could screen a broader and
26:16 --> 26:17broader population and derive
26:17 --> 26:18some incremental benefit from
26:18 --> 26:20expanding the screening criteria.
26:20 --> 26:22But as screening moves to lower
26:22 --> 26:23and lower risk populations,
26:23 --> 26:24you start to accrue,
26:24 --> 26:26you know on the population
26:26 --> 26:27level more harm than benefit.
26:27 --> 26:29So at some point we have to draw a
26:29 --> 26:30line and say this is the general
26:30 --> 26:32group that we think will benefit from
26:32 --> 26:34screening or the benefits outweigh the harms.
26:35 --> 26:39And so I think you know to to that point.
26:39 --> 26:42People kind of going full circle back to
26:42 --> 26:44where we we started the conversation.
26:44 --> 26:47People really need to think about the
26:47 --> 26:51fact that a these guidelines are based on
26:51 --> 26:54evidence of populations and we know that
26:54 --> 26:57in general provide more good than harm,
26:57 --> 27:00which is why they're recommended.
27:00 --> 27:01But that sometimes these things
27:01 --> 27:03need to be individualized.
27:03 --> 27:05There may be different guidelines based
27:05 --> 27:07on different societies and things that
27:07 --> 27:09you should talk to your doctor about.
27:09 --> 27:13But I want to end kind of where the
27:13 --> 27:15whole situation started when you were
27:15 --> 27:17talking about one of the reasons
27:17 --> 27:20you got into primary care was really
27:20 --> 27:21to keep people healthy,
27:21 --> 27:24and cancer screening is part of that.
27:25 --> 27:28What percentage of people actually
27:28 --> 27:31follow these guidelines and do you
27:31 --> 27:34have any advice for clinicians or
27:34 --> 27:37patients or family members in terms
27:37 --> 27:39of encouraging people to follow
27:39 --> 27:40these guidelines?
27:41 --> 27:43It's actually really desperate.
27:43 --> 27:45Depending on the screen
27:45 --> 27:46tests we're talking about.
27:46 --> 27:49So among women who are eligible
27:49 --> 27:50for breast cancer screening,
27:50 --> 27:52the United States, about 2/3 of
27:52 --> 27:54eligible women have been screened.
27:54 --> 27:55Which is quite high.
27:55 --> 27:56I mean it means that there are
27:56 --> 27:58some women who are eligible have
27:58 --> 28:00not been screened and there may be
28:00 --> 28:01good reasons for some of those,
28:01 --> 28:03and there may be not good reasons for others.
28:03 --> 28:05There may be still women who we ought to
28:05 --> 28:07be reaching and trying harder to reach.
28:07 --> 28:08But in general I think we've done a
28:08 --> 28:10pretty good job and I'd see it said
28:10 --> 28:12getting the word out about breast cancer
28:12 --> 28:14screening and bringing women into care.
28:14 --> 28:16Lung cancer screening is a bit of
28:16 --> 28:18a different scenario where only
28:18 --> 28:21about 10% of eligible folks have
28:21 --> 28:23been screened and part of it is
28:23 --> 28:24that I think again we need
28:24 --> 28:26to be better about messaging and
28:26 --> 28:27also about developing systems.
28:27 --> 28:30To make it easy for primary care doctors
28:30 --> 28:32to think of it and propose it to patients.
28:33 --> 28:35Doctor Ilana Richman is an assistant
28:35 --> 28:37professor in internal medicine
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:46and past editions of the program
28:46 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public
28:55 --> 28:57radio funding for Yale Cancer Answers
28:57 --> 29:00is provided by Smilow Cancer Hospital.

Information

Screening for Breast and Lung Cancers with guest Dr. Ilana Richman February 13, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095