By Francesca Lunzer Kritz
Special to The Washington Post
Tuesday, May 12, 2009
A Centers for Disease Control and Prevention study published in February noted a slight decline in the proportion of women having annual mammograms in just about every state, including Maryland and Virginia, as well as in the District.
The drop is so small, that researchers hesitate to call it a trend; they call it a "declining tendency." But it echoes similar findings in recent years. A National Institutes of Health study published in 2007 found that while the percentage of women 40 and older having yearly mammograms grew steadily between 1987 and 2000, those rates leveled off for three years and then declined. "The 2010 target for all women, 70 percent, was met in 2000, but the proportion fell to 66 percent in 2005," says Stephen Taplin, a senior scientist at the National Cancer Institute.
An earlier CDC study, an analysis of five years of telephone surveys, found that the percentage of respondents who had gotten a mammogram in the preceding two years dropped from 76.4 percent in 2000 to 74.6 percent in 2005. Those numbers would translate to 1.1 million fewer women nationwide getting routine screening, says Jacqueline Miller, medical director of the national breast and cervical cancer early detection program at the CDC.
The downward trend, however slight, has breast cancer experts worried. Mammograms can enable physicians to diagnose the disease at early stages, often before a lump can be felt. "When breast cancer is detected early, it often can be treated before it has a chance to spread in the body and increase the risk of dying from the disease," says Katherine Alley, medical director of the breast health program at Suburban Hospital in Bethesda.
The U.S Preventive Services Task Force, an independent panel of experts working under the Department of Health and Human Services, recommends that women older than 40 get a mammogram every one to two years. The task force finds the test most helpful for women between ages 50 and 69, for whom it says the evidence is strongest that screening lowers death rates from breast cancer. Other groups, including the American Medical Association, suggest a more rigorous schedule, saying the test should be done every year; insurers often pay for annual tests.
But experts say they are seeing gaps beyond two years in many cases. Carol Lee, chair of the American College of Radiology's Breast Imaging Commission and a radiologist at the Memorial Sloan-Kettering Cancer Center in New York, says many women understand that they need to have a mammogram but don't go back for repeat tests after the first one. In Bethesda, Alley said she has even heard anecdotal reports of breast cancer survivors forgoing recommended mammograms.
Why is this happening? For one thing, there are continuing questions about whether a positive mammogram, particularly for women in their 40s, is more likely to save a woman's life by having treatment started promptly or to expose her to lengthy, harsh treatments that might not have been necessary. That's because not all tumors eventually cause disease.
"At this time, it is not possible to be sure which very small breast cancers found by screening will cause problems and which breast cancers will not," says the NCI's Taplin. Therefore, he says, most of the medical community continues to rely on mammograms as a detective tool, but each woman has to decide for herself, together with her physician. "One thing we do know," he adds, "is that if women opt for mammograms, it does have to be done regularly, since they are of greatest value when physicians can compare changes that occur over time."
But Susan Brown, a nurse and head of health education for the Susan G. Komen Foundation, a breast cancer advocacy group, says, "Doubt over effectiveness is far from the only reason many women are not getting mammograms, and many might well choose to get the test if they could overcome other barriers." These include cost, fear of pain, and inconvenience, she said.
Mark Rukavina, executive director of the Access Project, a health reform advocacy group, says many people are forgoing preventive tests because they've lost their jobs and the insurance that often comes with it. (In this part of the country, the out-of-pocket cost for a mammogram ranges from about $135 to $270.) And although insurance co-pays for mammograms tend to range from $10 to $35 or a bit higher, Rukavina says, "even that small fee could seem insurmountable stacked against other costs right now."
One breast cancer specialist, Christine Pellegrino of Montefiore-Einstein Cancer Center in the Bronx, N.Y., says she thinks her hospital's experience supports the idea that money is a factor in the national trend.
"I believe that the reason that we are not seeing a decline in the rate of women going for their routine/follow-up mammograms in our area is that many of our patients are insured through Medicaid," which covers the entire cost, she says. So "they are not really affected by the bigger financial issues that end up causing other women to have to choose between their health care and more routine things, such as paying for food, housing, utilities or even the health care of their kids and spouses."
But cost may be a less onerous issue than some women expect. Some insurers -- CareFirst, for example -- do not charge a mammogram co-pay in some of their plans. And the Komen Foundation and community health centers can sometimes direct women to mammography centers that offer screenings free or on a sliding fee scale, based on income.
Arlington resident Marlene Alvarez, 44, a mother of three, has gotten a free yearly mammogram for the past five years -- including the year physicians found a spot on her films and she began treatment for breast cancer. (Ironically, an increase in her husband's income has Alvarez worried that she may not qualify for the free test next year.)
As for the pain of a mammogram, no one denies that having a breast flattened between two plates is an uncomfortable procedure. Sloan-Kettering's Lee notes that some mammography machines now have a spring release so the technician can release the pressure more quickly; and doctors say that a nonprescription pain reliever can lessen the discomfort.
Finding a place to have a mammogram is a problem in parts of the country, because of a shortage of radiologists and technicians. "But we have recently begun to see an increase in radiology students interested in learning to read mammograms specifically," Lee says. In any case, it is not much of a problem in the Washington area, which is host to several hospitals with mammography units, as well as free-standing centers such as Washington Radiology.