If women could schedule their own screening tests at more convenient times and sites, incurring lower costs, more women would comply, some doctors claim.

Yes. If radiologists don't accept self-referrals, some women won't get mammograms, and we'll miss early cancers. The purpose of mammographic screening is to find cancer before a patient or her doctor can feel it. If we can do that, there's a 70 to 90 percent chance of cure. Waiting till a tumor can be felt cuts the chance to about 40 percent.

Our purpose is to cure cancer, not to upset primary-care physicians or my colleagues in radiology who choose not to accept self-referral. An important strategy for getting women with no symptoms to have mammographic screening is to make it easy for them to obtain the exams.

It has been demonstrated several times in several areas that the major reasons women don't get mammography are that their personal physicians don't recommend it or that it's too expensive or inconvenient. Self-referred mammography is less costly because it can be done at a screening-mammography site with high volume and low costs. It is convenient because a woman can have it done on her own schedule.

And it gets around the problem of doctors not making referrals, because we're going directly to the patient and persuading her that it's her responsibility to be tested.

Clearly, radiologists who accept self-referred patients have a responsibility to make them aware of the importance of monthly self-examination as well as of a physical exam by a health professional.

We send the report to the primary-care physician as well as the patient. In the "ideal" situation, a woman has a physician who encourages an annual mammogram. Unfortunately, that's not reality, and self-referral is needed to find cancer when it's curable. -- Ronald G. Evens, MD Director, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis

No. Self-referral has been outside the mainstream of U.S. diagnostic radiology. Tradition and turf have limited the radiologist's role to that of consultant.

Changing that in order to find more cancers earlier is commendable -- but it can create medical, legal, economic and turf problems. Practice has protected radiologists from many of the reporting and follow-up duties required of primary-care physicians. Many radiologists simply aren't prepared to take on the overall responsibility that primary-care physicians traditionally have borne.

A woman who has mammography but not a complete breast physical exam has to be made to realize that she's not having a complete breast-cancer screening. And if she isn't advised effectively and a physical exam isn't done, a radiologist acting as primary-care physician may be held responsible for missing a potentially palpable but mammographically unseen carcinoma. Reporting and follow-up can be time-consuming -- and expensive, too. Instead of reporting to a physician, the radiologist must be prepared to explain the results to the patient.

The radiologist's time is by far the most costly component of mammographic screening, and even one or two discussions of abnormal findings a day can noticeably drive up the overall cost of operation. Some radiologists who've embarked on a self-referral practice have been very upset with the results.

The compelling desirability of getting more women screened is at least partially countered by the numerous problems experienced when radiologists accept self-referred patients. -- Edward Sickles, MD Chief, Breast Imaging Section, Department of Radiology, University of California at San Francisco

1990, Physician's Weekly, a Whittle Communications Publication; reprinted with permission