School of Advanced Nutritional and Medical Research

By Kim Painter
Februaary 26, 2007

I recently received a "Dear Kim" letter from the place where I've been getting my mammograms for the past six years. The clinic, like many nationwide, had gone out of the relatively low-paying business of screening women for breast cancer.

For me, it was no big deal: I called and had my records sent to another nearby clinic. I'll be having my yearly exam there in a couple of weeks, right on time.

But what if my old clinic had been the last in my community — or I had to wait several months because remaining clinics were overcrowded and understaffed? What if making one extra phone call had been just enough inconvenience to slow me down?

Or what if the letter hadn't mattered to me at all — because I had lost my health insurance or decided I'd had enough mammograms?

Those are among the scenarios health advocates are pondering in light of data that show mammography rates fell slightly in recent years. The percentage of women over 40 who said they had a mammogram in the previous two years fell from 76.4% in 2000 to 74.6% in 2005, the January report from the federal Centers for Disease Control and Prevention says. The study didn't show which women — richer or poorer, younger or older, more or less educated — were skipping mammograms or why.

But "we need to view this as a wake-up call. We're heading in the wrong direction," says Carol Lee, a professor of radiology at Yale University School of Medicine and chair of the American College of Radiology's commission on breast imaging. "If this decline holds up, it's very worrisome."

Diane Balma, vice president of public policy at Susan G. Komen for the Cure, says: "We're looking at a possible increase in deaths if we see this continue."

Experts cite several possible reasons for the drop:

•Fewer facilities, staffed by fewer radiologists and technologists, are offering mammograms — for reasons including high lawsuit rates and modest reimbursement — even as the number of women old enough to get screened increases.

•More women may be missing out on all sorts of routine health care because of inadequate insurance or other access problems.

•More women, for whatever reason, may be choosing not to get mammograms every one to two years in their 40s and every year after age 50 — even though studies show that doing so significantly reduces their risk of dying from breast cancer.

Declining access to routine health care seems the most likely explanation to Debbie Saslow, who directs programs on breast and gynecological cancer for the American Cancer Society in Atlanta. But shortages of facilities, doctors and technologists are causing longer wait times and inconvenience in some areas of the country, she says. "Nationwide, it's not a huge problem yet. But the trends are alarming," she says.

One immediate concern: The news about declining mammography rates puts recent news about declining breast cancer diagnoses in a new light. Saslow says: "It could be that it's not fewer women getting breast cancer but fewer women getting early diagnosis."

My recent column on the reluctance of many doctors to accept e-mail from patients prompted several to write that they remain unconvinced of any advantages. Most said that e-mail would just add unpaid labor to their busy days and that they preferred the reliability of phone calls and visits.

One response came from a registered nurse, Annie Bass of Rolla, Mo. Her husband, James, a general practitioner, already works every day of the week at all hours, she wrote: "When are you going to get it? We are tired and worn out but still work, for less and less. When a patient is sick, they are seen, regardless of ability to pay. … Until we have adequate compensation for what we do, forget the electronic age. It's just too costly, both in time and money."