Sidestepping screening:
What factors make women avoid annual mammography?
10/10/2005
Breast cancer has the highest incidence and mortality rates worldwide, and it is the second leading cause of cancer deaths for women in the U.S. While mammography is far from perfect, it remains the best screening tool available for the early diagnosis of breast cancer.
But studies show that about one in four women age 40 and older has not had a mammogram within the last two years. That figure is even worse for low-income women, with 40% admitting that they have never stepped within a few feet of the bucky. A recent study out of New Hampshire revealed that more than one-third of the women in that state who were eligible for mammography had never had the breast cancer screening test, or had not been tested in more than two years (Cancer, October 15, 2005, Vol. 104: 8, pp. 1726-1732).
This is despite the enthusiastic efforts by breast cancer screening advocacy groups to promote screening and boost awareness (American Cancer Society, May 9, 2005).
AuntMinnie.com took a closer look at some of the elements that may stop women, either intentionally or otherwise, from complying with annual screening recommendations. Of course, the issue is too complicated to attempt to summarize in a single shot. Still, breast imaging experts agree that certain broader obstacles continue to plague cancer screening programs, and continue to keep women out of screening facilities.
Personal experience
Chances are that every woman knows at least one person in her life who has been diagnosed with breast cancer, treated for breast cancer, or, worst of all, had a breast cancer scare. And if it happened to a friend (or even a friend of a friend), why couldn't the same fate befall her? As a result, many women subscribe to the "ignorance is bliss" school of thought. Getting an annual mammogram would then be akin to actively searching for a problem, pointed out Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital in Boston. The possibility of breast cancer is scary enough; the process of getting a mammogram only adds to that anxiety, he said.
For a woman who has undergone screening, one bad experience -- in the form of a false-positive mammogram or a benign biopsy -- can make for a lifetime of aversion, according to Dr. Carol Kornmehl a radiation oncologist in Ridgewood, NJ, and the author of The Best News About Radiation Therapy.
On the other hand, personal experience can have the opposite effect. "Women who have a family member or close friend with breast cancer are more likely to learn and see firsthand the advantages of yearly mammography," said Dr. Nancy Elliott of the Montclair Breast Center in Montclair, NJ. But if their experience at the radiology facility is a negative one, all good influence may go out the window, she added.
Even if fear and anxiety don't directly factor into the equation, women may skip out on annual screening simply because they lack the time.
"Women sometimes forgo timely mammograms because of life events such as taking care of a sick relative or losing a spouse. Because women take care of the world, we forget to take care of ourselves," said Dr. Beth Deutch, founder and medical director of HerSpace: Breast Imaging Associates in West Long Branch, NJ.
Dr. Elizabeth Shaughnessy, Ph.D., an assistant professor in the division of surgical oncology at the University of Cincinnati agreed: "Family care issues may be a problem as women age. Women tend to be primary caretakers of their own parents and spouses. Often, they delay their own care because they are dealing with the care of others who may be sick or dying."
Referring physicians
Assuming that many women will find any excuse to avoid annual screening, whose responsibility is it to make sure that she still does it? Physician referral for screening has proved to be the strongest evidence of why women get screening regardless of age, according to Cheryl Kidd, director of education for the Susan G. Komen Breast Cancer Foundation in Dallas.
Still, the influence of a primary care physician (PCP) does have its limitations. Shaughnessy stressed that each generation faces medical management differently. For example, women born before the baby boomer era tend to follow their physician's recommendations before taking initiative in their own care. Unless the physician tells them to obtain a mammogram, they most likely won't. On the other hand, younger generations take a different view of self-care. They are more in tune with their bodies and are more apt to undergo screening tests.
Consistently educating referring physicians about mammography's strengths and weaknesses is the key. A large medical organization may support screening, but if an individual's doctor does not, his or her patient is not likely not avail herself of those services, Kopans said.
Public policy
Pink ribbons and fundraising walkathons aside, a mixed message is being delivered to women as to the details of screening. Government and professional organizations advocate mammographic screening for breast cancer, but differ on what age, and how often, a woman should screen. Consumer and breast cancer organizations also offer potentially conflicting information. Some hardliners believe that women have been misled about the benefits of screening in women ages 40-49, stating that there is no proof that mammography reduces breast cancer mortality in women younger than 50 (National Breast Cancer Coalition, May 23, 2004).
The Komen Foundation, the American Medical Association (AMA), the American Cancer Society (ACS), and the American College of Radiology (ACR) recommend yearly screening beginning at age 40. The U.S. Preventive Services Task Force (USPSTF) and the National Cancer Institute (NCI) recommend screening every one to two years beginning at age 40.
There are a number of reasons for the general lack of consistency in screening guidelines, and published research doesn't always clear up matters. To attempt to summarize the myriad breast cancer screening trials in a few words would be a disservice. Suffice it to say that results may vary depending on trial methodology, patient population, country of origin, and possibly even editorial policy of the journal that has opted to publish the study. Unfortunately, when the lay press gets hold of this information, it tends to present it in a sensationalized manner, and without much in-depth explanation as to the limitations that are inherent in scientific research.
So whose advice should a woman heed? That may very well depend on which breast cancer screening study is in vogue that particular week. "There are no data that, when properly analyzed, have ever shown that any of the parameters of screening change abruptly at any age," wrote Kopans in a recent commentary. "The age of 50 is completely meaningless and is arbitrary. Although many 'experts' understand this, opponents of screening have not found it necessary to alert women and their physicians to this fact" (The Death of Mammography by René Jackson and Alberto Righi, Caveat Press. Ashland, OR, 2005, p. 144).
Access
Mammography services currently face many challenges: it is the most frequently litigated radiology modality; not enough radiologists are choosing careers in breast imaging; and reimbursement rates are still dismally low. As a result, mammography centers are closing their doors, forcing women to travel longer distances for a screening mammogram, endure a longer wait time, or forgo the test altogether.
The average wait in New York is 40 days or more (versus two weeks in the later 1990s). In some parts of the country, such as Florida, there is a three-month wait for a screening mammogram. Since 1990, the percentage of mammography facilities open in the U.S. has dropped by almost 9%.
"Often, it is difficult to obtain an appointment, or there is a lengthy waiting period. Some women may just give up and then forget to make the appointment," Deutch said.
If changes aren't forthcoming in the reimbursement rates, access will become even more limited, according to Kidd. Low reimbursement serves as a disincentive to the development of breast cancer medical expertise and impedes patient access to quality care, she said.
A recent survey in Cancer found patients looking at wait times of one to two months, thanks in part to unfulfilled breast imaging positions (Cancer, August 1, 2005, Vol. 104:3, pp. 491-498).
Lead author Dr. Robert Smith from the American Cancer Society pointed out that "radiologists do not have a patriotic duty to read mammograms or to specialize in mammography ... (but) from a broad public health perspective, we have a collective duty to women at risk for breast cancer to acknowledge that we may be about to face a crisis and not wait for that crisis to occur before we seek solutions" (Reuters Health, August 26, 2005).
Cost
Cost has often been cited as a barrier to screening mammography. However, the ACS holds that lack of accurate knowledge of coverage rather than actual costs have deterred many women from screening.
Most insurance covers screening mammography, and most states have laws that mandate health insurers to reimburse some or all of the cost of a mammogram. Medicare also pays for a yearly screening. But women 65 years and older, and women earning less than $20,000 per year, are more likely to misunderstand their coverage, according to the ACS. This narrows down the pool of women obtaining yearly mammograms to women with higher incomes and better education regarding their insurance status.
Matters are even more dire for impoverished women without insurance, many of whom don't have access to healthcare or are contending with doctors who offer no advice on breast cancer screening, Kornmehl said. Their lack of compliance may also be fueled by a lack of understanding of the point of screening.
Some states have set up programs that would reduce or even eliminate health insurance co-payments in an effort to encourage women to comply with screening guidelines. But that loss of income will need to be offset by someone.
"Unfortunately, insurance companies and the federal government think mammography is too expensive, so women have to make a decision about what is important," Elliott said. "Is it the hairdresser, the massage, the restaurant, or the mammogram?"
