By Phil Evans, M.D., FACR

Women have had a hard fight with Capitol Hill when it comes to health care. While the medical community is making phenomenal advances in treatment and prevention of disease every year, legislation too often is overturned to require insurance companies to cover these life-changing and often lifesaving innovations. Such was the case for tomosynthesis, or what is more commonly known as 3-D. In the past, only Medicare would cover 3-D mammograms as part of the breast cancer screening process, and even that decision was not made until 2015.

This year, a breakthrough was made in women’s cancer prevention. As of Sept. 1, 2017, all Texas commercial insurance companies that offer coverage for women 35 and older became required to cover 3-D mammograms thanks to House Bill 1036, which was signed into law June 15 by Gov. Greg Abbott. UT Southwestern was on the front lines of research and collected data in collaboration with research centers across the country to move 3-D mammography through Food and Drug Administration (FDA) approval.

Why do women need 3-D mammograms?

The new law has an interesting personal story behind it that helped bring to light the importance of 3-D mammograms. The bill originally was introduced by Texas Rep. Senfronia Thompson (D-Houston), whose own breast cancer diagnosis inspired her to draft the bill. Throughout her arduous cancer journey, Thompson underwent multiple tests, mammograms, biopsies, and radiation. A few key points stuck with her. The first was that 3-D mammograms can see tumors or lesions as small as 2 millimeters, and that women who receive them are less likely to need biopsies. The second was that not many women could easily access 3-D mammograms because current legislation required only 2-D, or digital, mammograms to be covered.

She got to work with colleagues and pushed the bill through. Because of their hard work and dedication to the cause, the bill was passed through the House and the Senate within two months. Gov. Abbott’s passing of the bill makes Texas the seventh state to include 3-D mammograms as part of its breast cancer screening process since its FDA approval.

Many centers throughout the country worked tirelessly, including UT Southwestern Medical Center, to acquire FDA approval for 3-D mammography. Since its FDA approval in February 2011, it has been used by more and more facilities in the U.S. and Europe and has proven to be the best mammogram for early detection of breast cancer for two important reasons:

• The detection rate of breast cancer is greater with 3-D mammography than with a standard digital mammogram by as much as 41 percent
• 3-D mammography decreases the number of women who have to come back for additional screening, known as the recall rate, by as much as 30 percent by allowing radiologists to see through dense breast tissue

To the patient, there is not much of a discernible difference in comfort between a 2-D and 3-D mammogram. In both, each breast is pressed between two plates, once vertically and once horizontally, for 10-15 seconds while an image is made. Breast compression without causing pain provides the best picture for the 2-D mammogram. The breast may not need to be pressed as firmly for the 3-D mammogram.

The 3-D mammogram also yields a different type of picture. Whereas the 2-D image gives us a flat image of the inside of the breast, the 3-D mammogram yields many 1-millimeter image “slices” that can be viewed individually or together to see even the smallest abnormality in the breast tissue. Tomosynthesis also can be used to guide breast imaging radiologists during biopsy in order to remove tissue that cannot be detected by ultrasound or other imaging methods. At UT Southwestern, we use a combination of both 2-D and 3-D mammography to get a complete view of patients’ breasts.

The 3-D mammogram is almost always performed in combination with a standard 2D mammogram. This practice results in twice the radiation dose of a 2D mammogram, although the exposure is still within safe acceptable limits. Now, with the advances in 3-D mammography, women can have only the 3-D images taken, and a 2-D image can be reconstructed or “synthesized” from the 3-D images without the additional radiation exposure.

Who needs to be screened for breast cancer and when?

While breast cancer screening recommendations vary depending on a woman’s personal risk, one common thread never changes: Early detection is key. We recommend that women at average risk for breast cancer get a mammogram starting at age 40 and continue them yearly. Women at higher risk, such as those with a personal or family history of breast cancer, should talk to their doctors about starting screening earlier than age 40. Breast cancer is the second most commonly diagnosed cancer among women, but since 1990 deaths from the disease have decreased nearly 40 percent because of regular screening and improvements in treatment.

By the end of 2017, an estimated 250,000 new cases of invasive breast cancer will have been reported. Many advanced cases and deaths from breast cancer could be prevented with earlier detection, and 3-D mammography, particularly now that it’s covered for more Texas women, is a powerful tool to make that happen.