Too many American women skip mammograms, which are becoming harder to get because of a growing shortage of providers, say government advisers who are recommending better access to the breast-cancer scans.
Mammograms are not perfect, but no other technology has proved better at detecting breast cancer early, when it is easier to treat, the Institute of Medicine reported Thursday.
But only about 60 percent of the women old enough to need routine mammograms get them because of lack of insurance, a system that lets women fall through the cracks as well as public confusion or fear about cancer screening. Those are the findings in an exhaustive review of breast-cancer detection by the prestigious scientific group.
“Mammography saves lives and we need to figure out a way to get it to more patients more uniformly,” said Dr. Etta Pisano, chief of breast imaging at the University of North Carolina, Chapel Hill, who co-wrote the report.
For women who are seeking mammograms, the closure of scanning centers suggests “a serious decline in access,” the report said.
In parts of Florida, three-month waits for an appointment are common, the report said. In New York City, the average wait for a first-time mammogram is more than 40 days, compared with two weeks in the late 1990s.
According to government inspection records, the number of mammography facilities has dropped by 8.9 percent since 2000.
“We need to do something to address that,” Pisano said.
The decline is thought to be due to low insurance reimbursement for mammograms, rising malpractice litigation and fewer radiologists choosing breast imaging instead of other specialties, the scientific committee said.
Rise of false positives
The shortage comes even as more women — an additional 1.2 million each year — become old enough to need routine mammograms. Yet no more than three dozen breast-imaging subspecialists — the radiologists with the most mammography expertise — enter the profession each year.
At the same time, the number of false-positive mammogram readings — when something suspicious turns out to be noncancerous — has nearly doubled, the report found. That may be due partly to radiologists practicing “defensive medicine” in hopes of avoiding lawsuits.
Women have a one in 10 risk of a false-positive mammogram, leading to unnecessary repeat testing and the anxiety that women often cite for skipping mammograms.
The committee recommended that:
- mammography facilities specially train nonphysician workers to prescreen mammograms. These employees would not replace radiologists but would do some of the less critical work so sites can perform more scans.
- the United States copy practices from other countries that get more women in for routine mammograms. Britain, for example, contacts every woman when she is due for a government-paid mammogram. In the United States, women seek the $75 to $150 X-rays on their own or at the urging of a doctor. While Medicare pays for older women, a government program to give free mammograms to certain uninsured women reaches only a fraction.
- the easy-to-perform X-ray be offered at more locations but that mammograms be read at a few centralized sites, to maximize the number of radiologists.
- mammogram quality be improved by lowering the false-positive rate with programs that help radiologists track their performance or by using computer programs to double-check the X-rays.
One of the recommendations drew immediate fire from the American College of Radiology, which said mammogram “prescreeners” would be dangerous.
“We should not lower the bar so that women have a perception of increased access, only to find that the access is to inferior care,” said Dr. James Borgstede, chairman of the group’s board.
Instead, the radiology group is pushing for better mammogram reimbursement and other steps to increase providers.