Officials ponder drop in mammograms as 1.1 million fewer women are screened

Washington -- The number of women having mammograms began to decline in 2000, and researchers and clinicians are trying to understand why this trend is occurring and how it can be reversed, given the lifesaving nature of the tests.

Breast cancer remains among the most commonly diagnosed cancers among women, said Jacqueline W. Miller, MD, a medical officer at the Centers for Disease Control and Prevention who focuses on cancer prevention and early detection. Yet the number of women 40 and older who reported having a mammogram within the two years preceding a recent CDC survey decreased by 1.8% between 2000 and 2005, she said.

Dr. Miller was among the speakers at a May 5 Capitol Hill briefing on mammography trends sponsored by the Society for Women's Health Research, a nonprofit organization based in Washington, D.C.

Although the screening decline might seem small, it translates into 1.1 million fewer women getting routine evaluations, Dr. Miller said.

And improving screening is the mantra of radiologists, said Etta D. Pisano, MD, director of the University of North Carolina School of Medicine Biomedical Research Imaging Center in Chapel Hill. "There are over 40,000 women dying each year of breast cancer, which means we found their cancers too late," she said. Mammography greatly increases the odds that the cancer will be caught early, when it is most curable.

The value of screenings has long been apparent, said Rachel F. Brem, MD, director of Breast Imaging and Intervention at George Washington University Medical Center in Washington, D.C. The breast cancer death rate had been increasing until mammography began to be used more widely, she said.

A large study found that 60% of the decrease in mortality was due to improved screening rates and 40% to improved treatment. Found early, 95% of breast cancer is curable, Dr. Brem said.

Reimbursement problems

Given the known benefit of screening, the possible reasons for its decline are receiving scrutiny. A drop by about 6% in the number of mammography facilities in the United States may be contributing to the decline, Dr. Brem said. Studies show that the greater the distance to a facility, the less likely a woman is to make the trip.

Medical centers also have found that they lose money with screenings because of low reimbursement rates from Medicare and other insurers. Screenings are considered "loss leaders," she said.

In addition, there is a shortage of radiologists to staff centers, Dr. Brem said. Young radiologists are reluctant to enter the field, fearing heightened exposure to liability. Delayed diagnosis of breast cancer is the No. 1 reason for successful liability lawsuits, she noted.

Increased reimbursement for mammography that covers the actual costs of the procedure, tort reform to limit the exposure of the radiologist to liability and health insurance that covers the procedure for all women could help reverse the drop in utilization rates, Dr. Brem said.

She pointed to the importance of adhering to the Mammography Quality Standards Act of 1992, which defines minimal requirements for radiation dose, image quality, radiologist training and continuing education.

The AMA has long supported adequate reimbursement for screening mammography as well as steps to ensure high-quality screening with properly functioning equipment. The Association recommends annual screening mammograms and clinical breast exams for asymptomatic women ages 40 and older.

Dr. Brem urged that the MQSA be extended to include all image-guided breast biopsy procedures as well to ensure that biopsies of suspicious findings follow standards similar to mammograms so that "women can not only have high-quality and appropriate mammography, but minimally invasive biopsies as well."

The search also is on for better cancer detection methods, the presenters said, because, although current methods are effective, they aren't perfect.

Computer-aided detection is an option that allows radiologists to better compare mammograms and determine whether a new abnormality is "friend or foe," Dr. Brem said. The technique helps radiologists detect breast cancer about 15 months earlier than regular technology, she added, leading to greater survival rates.

The increasing use of electronic medical records allows easier access to previous screenings, thereby enabling radiologists to detect changes more readily, she said.

And tailoring screening so that high-risk women are treated differently than are women of average risk is a concept gaining momentum. High-risk women need more sensitive screening tools, concluded a 2004 Institute of Medicine report, "Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis."

Three imaging tools are already known to improve detection for women at high risk for breast cancer, Dr. Pisano said. They include digital mammography, ultrasound and magnetic resonance imaging.

One large trial determined that digital mammography was more accurate in diagnosing cancer in women with dense breasts; another demonstrated that the addition of MRI improved detection of small, node-negative cancers while mammography found more noninvasive cancers. Also, women with cancer in one breast were found to benefit from an MRI screening in the other breast, Dr. Pisano said.

Given the data on screening, the American Cancer Society issued a new guideline last year that all women with a lifetime risk of breast cancer greater than 20%, which includes those with BRCA1 or BRCA2 gene mutations or those who have a family history of the disease, should have an annual screening MRI as well as an annual mammogram.