Sidestepping screening: What factors make women avoid annual mammography?
Breast cancer has the highest incidence and mortality rates worldwide, and it is the second leading cause of cancer deaths for women in the United States. 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, forty and older, have 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 are eligible for mammography have either never had the breast cancer screening test or have not been tested in more than two years (Cancer, September 12, 2005).
This is despite the enthusiastic efforts by breast cancer screening advocacy groups to promote screening and boost awareness (American Cancer Society, May 9, 2005).
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 an 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 first hand 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.
“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/medical director of HerSpace: Breast Imaging Associates in Monmouth, 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 proven to be the strongest evidence 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 in the pre-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.
Education is 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
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 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 less than 50 (National Breast Cancer Coalition, May 23, 2004)..
The Komen Foundation, as well as the American Medical Association (AMA), the American Cancer Society (ACS) and the American College of Radiology (ACR) recommend screening yearly beginning at age 40. The United States Preventive Services Task Force (USPSTF) and the National Cancer Institute (NCI) recommend screening every one to two years beginning at age 40.
There are various reasons for the controversy in screening. One is that some of the trials were flawed in one way or another, which skewed results. Another is the tendency of the media to sensationalize news which, in turn, influences public opinion. In addition, in the 90s, there was a major cover-up at a government agency ignoring facts and trivializing the significance of breast cancer screening among women in their forties.
So whose advice should a woman heed? “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 fifty 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 Rene 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. Mammography centers are closing their doors, forcing women to either 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,” said Deutch.
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.
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 American Cancer Society (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 it down to women with higher incomes and better education, regarding of their insurance status.
Matters are even more dire for 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, said Kornmehl said. Their lack of compliance may also be fueled back 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,” said Elliott. “Is it the hairdresser, the massage, the restaurant, or the mammogram?”
Rene’ Jackson RN BSN MS
Freelance Health Writer
“The Death of Mammography”
Rene’ Jackson RN BSN MS
Alberto Righi, MD
Published November 2005
Caveat Press
Read the press release, reviews,
and excerpts from the book at: http://www.rjacksonrn.com;
[email protected]