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updated 10/15/2008 5:48:20 PM ET 2008-10-15T21:48:20

There are lots of good reasons for women 40 and older to get mammograms every year or two, namely potentially cutting their risk of death from breast cancer.

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But many are still avoiding the screening. A new report from the American Cancer Society show that mammography rates appear to be stabilizing or slightly declining after increasing for more than a decade. In 2005, 66.5 percent of women 40 and older reported having a mammogram in the past two years, versus 70.1 percent in 2000.

What's behind the decline? Experts have suggested that a 2002 study that tied hormone replacement therapy to an increased risk of breast cancer and heart disease is to blame. When women stopped seeing their doctors to treat menopausal symptoms, they may have also stopped going for mammograms.

Another possible cause is the current nationwide shortage of mammography technicians and qualified radiologists, in part due to lower reimbursement rates for the procedure and a relatively high rate of lawsuits, says Dr. Marisa Weiss, a practicing breast cancer oncologist and founder and president of the nonprofit Breastcancer.org. If a woman calls to make an appointment for a mammogram and has to wait a month or more, she may lose her motivation or opt out when the date finally rolls around.

And then there are the excuses that doctors and technicians hear over and over again — "it hurts" — as well as new reasons researchers are uncovering.

"In many ways," Weiss says, "mammograms are not set up to succeed."

In fact, a small American Cancer Society study published in Oncology Nursing Forum in April shows that, of 116 African-American women interviewed, 77 percent of those over 40 reported having a mammogram in their lives, 29 percent in the past year. But medical records showed that only 40 percent of the women had actually ever had a mammogram, and only 9 percent in the past year. While it's possible that some screenings were not properly documented, the findings suggest that patients tend to over-report their screening levels.

New research from Brown University and Harvard Medical School also shows how even low co-pays for mammograms can lead to a sharp decrease in breast cancer screening rates, says Dr. Amal Trivedi, lead author of the study and assistant professor in the department of community health at Brown's Warren Alpert Medical School.

In a review of more than 366,000 women between the ages of 65 and 69 who were in Medicare managed-care plans, researchers found that biennial breast cancer screening rates were 8 percent to 11 percent lower in cost-sharing plans. The finding is particularly worrisome, Trivedi says, given the likelihood that companies will continue shifting more of the burden of rising health-care costs onto consumers.

Still another factor that might hold women back from getting a mammogram is the growing availability of genetic tests, one of which can tell whether or not a woman carries a BRCA-1 or BRCA-2 mutation associated with many cases of hereditary breast cancer.

The concern is that if a woman receives negative test results without proper counseling she might assume that she does not need to have regular mammograms anymore, says Dr. Erin Tracy, an ob-gyn at Massachusetts General Hospital. But, of the more than 192,000 American women who learn they have breast cancer every year, only 5 percent to 10 percent of them have a hereditary form of the disease, according to the National Cancer Institute.

Breast cancer in the United States

Fear not
Experts say if you are avoiding a mammogram, for whatever reason, there are certain things you can do to make the experience more comfortable. First, ask for recommendations from friends. If they've had a good experience at a facility, chances are you might, too, says Weiss. Bringing someone with you can also make the appointment less stressful and help make sure you follow through.

Seeking out a center that uses digital mammography can also cut down on the wait for results and lessen the likelihood that you'll have to come back to have more pictures taken. An accredited facility is also more likely to have experienced technicians and stay around for a while, so you don't have to worry about the center's doors closing, taking your medical records and yearly reminders with it.

If it's the pain you're worried about, don't schedule your screening right before your period when your breasts may be tender. You should also ask if the center provides MammoPads — soft, warm, foam pads that attach to the compression plates — and request a technician who is particularly good at dealing with squeamish patients. Some centers even allow women to control the rate of compression themselves, which can take some of the anticipatory anxiety out of the screening. Taking a Tylenol a few hours before your appointment can also make a slight difference, says Dr. Amy Balis, a radiologist who specializes in breast imaging at Baylor Medical Center at Irving.

And, of course, some perspective is helpful, too.

"Five minutes of pain is worth a lifetime of not having breast cancer," Balis says.

© 2012 Forbes.com

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