Cancer Waits for No One

ACR continues to stress the importance of lifesaving screening exams to its members and their patients.

Stamatia V Destounis, MD, FACR and Judy Yee, MD, FACR

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By Stamatia V. Destounis, MD, FACR, breast radiologist and chair of the ACR Commission on Breast Imaging, & Judy Yee, MD, FACR, chair of the ACR Colon Cancer Committee, Professor and University Chair, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine

Many people are aware that October is Breast Cancer Awareness Month, and reminders to attend to breast health have spread far and wide for decades. Many may not know that coverage of non-invasive, safe and accurate CT colonography (CTC) for Medicare patients is imminent — with final approval expected next month. The numbers around breast and colon cancer are staggering, and efforts to educate physicians and their patients must be top of mind year-round.

The U.S. Preventive Services Task Force (USPSTF) currently recommends all women get screened for breast cancer every other year, starting at age 40 and continuing through age 74. Breast cancer screening beyond age 74 was given an “I” recommendation by the USPSTF, which means insufficient evidence to make a recommendation. USPSTF guidelines say adults ages 45 to 75 should be screened for colorectal cancer. For colon screening, the decision to get screened between ages 76 and 85 should be made on an individual basis, according to the agency, and if you are older than 75, you should discuss the test with your physician.

This month, two notable guest authors address the necessity — if not the urgency — of getting breast and colon cancer screening.

Numbers Matter: Assessing Breast Cancer Risk

Breast cancer continues to be the leading cancer diagnosis in women, with approximately one in eight women diagnosed with invasive breast cancer in their lifetime. An estimated 310,720 new cases of invasive breast cancer will be diagnosed in U.S. women in 2024, with an additional 56,500 cases of Ductal Carcinoma in Situ (DCIS). It is estimated that approximately 2,790 new cases of invasive breast cancer will be diagnosed in men in 2024. Breast cancer is one of the leading causes of cancer-related death in women in the U.S. (second only to lung cancer), with an estimated 42,250 deaths. An estimated 530 men will die of breast cancer in 2024.

Annual mammography screening continues to be the most effective breast cancer screening tool. Annual screening detects breast cancers early, when they are small and have not metastasized, and are easier to treat with minimal surgical and medical treatment. When breast cancer is detected early and has not spread, the five-year survival rate is 99%. Annual screening mammography is the only screening tool — as has been proven by randomized controlled trials and observational studies — to decrease mortality from the disease by 44% (along with advances in cancer treatment). In addition, annual mammography attendance before a breast cancer diagnosis is predictive of overall survival. Screening should begin at age 40. Screened women in their forties are more likely to have smaller, early-stage, node negative disease than unscreened women. Screening should also continue past age 74, without an upper age limit, unless severe comorbidities exist which limit life expectancy. One in five cancers occur in women 75 and older, and studies have confirmed that screening over age 74 results in benefits including deaths averted and life-years gained. This is why ACR along with other organizations and societies continue to recommend annual mammography screening beginning at age 40 and continuing past age 74 for all patients considered at average risk of the disease.

Recent ACR recommendations have gone a step further, recommending all patients undergo a risk assessment by age 25, especially minority women and women of Ashkenazi Jewish heritage. Mounting evidence shows that Black and other minority women develop and die from breast cancer prior to age 50, or even age 40 — more often than non-Hispanic White women. This is because Black and other minority patients are more likely to be diagnosed at a younger age, to be diagnosed with aggressive or triple negative breast cancers and are 127% more likely to die of breast cancer than White patients. They are also 72% more likely to be diagnosed with breast cancer, and 58% more likely to be diagnosed with advanced breast cancer. Even with nearly equal incidence rates, Black patients are still 42% more likely to die of the disease. In undergoing a risk assessment evaluation, patients can better understand their breast cancer risk and their best screening options. This can potentially improve existing disparities and increase access to screening and equitable treatment. The early assessment of risk allows for those who do have increased risk of breast cancer to be identified and given the opportunity to begin screening interventions earlier.

For those who are noted to be at higher risk — such as those with a gene mutation, history of chest radiation at an early age, a strong family or personal history of breast cancer, or with calculated lifetime breast cancer risk of 20% or more — ACR recommends that these patients begin screening MRI between ages 25 to 30. The ACR also recommends beginning screening mammography earlier, between ages 25 to 40, depending on specific risk factors.

Annual screening mammography is still the best way to find breast cancers early and save lives.

Ensuring Access to All Non-Invasive Colon Screening

Colorectal cancer (CRC) is the third most common cancer in men and women. Overall, when considering men and women together, CRC is the second leading cause of cancer death in the U.S. Racial disparities exist, with Black patients about 20% more likely to develop CRC and about 40% more likely to die from it compared to other groups. Additionally, alarming trends have been identified — including an increased number of cases among younger patients, at a more advanced stage and in the left colorectum. The fight against CRC should not only include understanding the cause of the increasing incidence of cases but continuing to increase equitable access to screening for all individuals.

Two CRC screening test categories are recognized in joint guidelines published in 2008 by the American Cancer Society (ACS), the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF) and ACR. The first category includes tests that detect the precursor polyp and cancer (colonoscopy, flexible sigmoidoscopy, double-contrast barium enema and CTC), and the second category includes tests that detect cancer (stool-based tests). Since prevention of CRC is the main goal of screening, tests in the first category — which allow detection of the precursor lesion for removal — play a more pivotal role. In 2016, the U.S. Preventive Services Task Force (USPSTF) expanded support of test options for CRC screening and for the first time recommended CTC as a valid test option. CTC was placed in the direct visualization category, similar to colonoscopy and flexible sigmoidoscopy. The USPSTF guideline also included stool-based test options consisting of fecal occult blood test (FOBT), fecal immunochemical test (FIT) and a multitarget stool DNA (mt-sDNA) test.

Approximately one-third of the eligible population have not undergone guideline-recommended CRC screening. As highlighted by the ACS, all qualified screening test options should be supported in order to improve screening rates and making more choices available will increase the likelihood of screening. The best test is the one that gets done. CTC is a proven, minimally invasive and safe screening test that does not require sedation and allows patients to return to normal daily activities immediately following the test. It can accurately identify both the precursor polyp and cancer to help save lives.

Although major health insurers have provided screening CTC coverage for years, there has been limited use of CTC for screening in this country. This has been predominantly attributed to the lack of approval for reimbursement by the Centers for Medicare and Medicaid Services (CMS). The size of the Medicare population continues to grow and with the decrease of the screening age from 50 to 45 years old, there is an increased need for screening tests to cover an even larger number of eligible patients.

The ACR has strongly advocated for CMS coverage of screening CTC for more than 15 years. Currently, CTC is the only CRC screening test included as a valid test option by the ACS and USPSTF, but not covered by Medicare. However, this is expected to change with the announcement of Medicare coverage for screening CTC in the 2025 Hospital Outpatient Prospective Payment System (HOPPS) and 2025 Medicare Physician Fee Schedule (MPFS) proposed rules. With the looming finalization of the approval by CMS — which would add coverage for screening CTC effective Jan. 1, 2025 — we can expect CTC to be used more broadly to improve screening access for Medicare beneficiaries and underserved populations. Coverage of screening CTC could help to reduce income-based disparities for individuals avoiding optical colonoscopy due to invasiveness, the need for anesthesia, complications and risks or time away from work. This will provide a valuable test option to the armamentarium in the fight against CRC. The proposal by CMS supports coverage of screening CTC as a replacement for the barium enema, a test that has been used only in limited circumstances and typically not for colorectal cancer screening.

Screening CTC is poised to obtain CMS approval, and we must be ready to support an increased volume of screening CTC studies. There must be adequate education of radiologists who will be performing CTC as well as assuring education of trainees and technologists. ACR provides wide-ranging support for CTC programs to assure high-quality exams and has compiled a comprehensive list of resources. The ACR Practice Parameters and Appropriateness Criteria include state-of-the-art patient preparation and low radiation dose CTC protocols. Sites performing CTC are encouraged to join the ACR CTC Registry, through which participants gain access to patient and procedural data and quality feedback reports. Use of the CTC Reporting and Data System (C-RADS) is recommended to standardize the reporting of colorectal and extra-colonic findings. The time has finally come for CTC to take its rightful place as a screening option for all patients.