POINT OF VIEW
The Crisis in Mammography
BY KATHIE-ANN JOSEPH, M.D., M.P.H.
About 200,000 new breast cancer cases are diagnosed in the United States each year, and about 40,000 women die from the disease. The American Cancer Society recommends routine screening mammography starting at age 40. As a result, more than 1.2 million women become eligible for mammography screening each year but the number of breast imaging specialists who enter the profession annually is failing to keep up with demand. About 40 percent of women between the ages of 40 and 64 and 36 percent of women over the age of 65 do not get mammograms each year. For African-American women, who have the worst survival rates from breast cancer, overall, of any ethnic group at every stage, the screening rates are no better.
Earlier this year, the Institute of Medicine issued a report on breast cancer detection, in which it cited a crisis in mammography. The report warned that the United States is quickly losing ground in its ability to offer mammography to women. As a result, many women are, and will continue to be, denied timely mammograms. Although there are 20,000 radiologists in the United States who can interpret mammograms, only about 2,000 radiologists now specialize in breast imaging. The reasons for the exodus from this specialty include low reimbursements, high stress, and a fear of lawsuits.
Medicare reimbursements are particularly low. Medicare Part B pays $67.81 for a screening mammogram, but that amount fails to take into account the time involved in counseling the patient before the procedure. Even worse, Medicare's hospital outpatient payment system reimburses hospital-owned outpatient services a technical fee of $34.80 for diagnostic mammograms, mammograms intended to look for an abnormality seen on a screening mammogram or to follow-up patients who have already had surgery. As a result, the more of these types of mammograms most screening centers perform, the more money they lose. The reality is that mammography centers simply cannot break even.
In the United States, breast cancer leads to more malpractice claims than any other medical condition. Generally, this is due to a delay in diagnosis. Only neurological impairment in newborns surpasses breast cancer in paid claims. An increasing number of claims related to breast cancer are now filed against radiologists who interpret mammograms.
As a result, the number of mammography facilities has declined in the United States from 9,400 in 2000 to 8,600 in 2003, a decline of 8.5 percent. The low reimbursements combined with rising malpractice rates have compelled many imaging specialists to leave the specialty and deterred young radiologists from entering the field. The number of applications for mammography fellowships across New York City has declined by as much as 75 percent. Amazingly, this decline has occurred within the space of a single year in some institutions.
The decline in mammography facilities and specialists is creating a significant access problem for women. The Institute of Medicine report said that we are on the brink of a crisis. I would argue that we are already in the midst of a crisis. This is a countrywide problem, not an isolated one. It is a problem facing cities all over the country and major academic institutions in this city are already having to grapple with these issues.
Many women across the United States who are calling to request screening mammograms are experiencing waiting times of between four to six months. Five years ago, the waiting time was 14 days. The increase in waiting times is occurring at both large and small centers. The concern, of course, is that the gains made in decreasing overall mortality rates over the years due to early detection may reverse as a result of delays in obtaining mammograms. While this is a problem affecting all women, poor and minority women who already have low screening rates may stand to suffer the most.
What is the answer to this dilemma? Unfortunately, there doesn't appear to be a quick fix, but there are things that can be considered. One controversial solution to the personnel shortage is to train nurses or technicians to read mammograms, something now being done in Britain. Technological advances may fill in gaps. For example, computer-aided detection, CAD where the computer acts as a second reader of a mammogram, in addition to the radiologist already exists, but this technology is neither proven nor widely available.
The American College of Radiology has lobbied Congress to increase reimbursements. Legislation that would increase payments would tie in to new technologies such as digital mammography. This, too, is treading on dangerous ground, however, since digital mammography and other emerging technologies have not been scientifically proven to be better than standard imaging. Many centers are moving toward a fee-for-service payment system, further compounding the access problem for many women who cannot afford to pay out of pocket for a mammogram. Worse, women may choose to go to centers run by inadequately trained personnel who may be the only centers readily available to accommodate them.
For the time being, breast cancer is not preventable. Mammography is not perfect; in fact, it can miss breast cancer in 17 percent of cases. But most would agree that mammography has contributed to earlier detection and, therefore, has saved lives. In the short term, we work closely with our imaging center to accommodate those women with new suspicious findings. We warn our patients not to procrastinate and book their next mammogram appointment at least six months in advance. The opening of our new screening imaging center should help to alleviate some of the delay in obtaining appointments. For poor, uninsured women, there is the Healthy Women Breast Partnership, partly funded by New York State, which offers free mammograms to women and pays for surgery and reconstruction and adjuvant therapy for women diagnosed with breast cancer.
What is most rewarding about my specialty is that despite the diagnosis of cancer, the majority of my patients survive and enjoy fulfilling lives. This, I believe, is tied directly to early detection, as well as the broad array of adjuvant therapy now available to our patients. Mammography is the front door in breast cancer detection. We cannot allow that door to close on millions of women.