Mammogram Seeking Acceptance : Why Few Take the 15-Minute Test for Early Breast Cancer
Six months ago, Linda Boegner decided to undergo mammography, an X-ray procedure that creates an image of the breast to help radiologists detect cancer.
The 38-year-old Brentwood woman had not felt a lump in her breast or noticed any other worrisome symptom of breast cancer. “I did it as a preventive measure,” said Boegner, an office manager who later learned her mammogram was normal.
Boegner was following the recommendation of the American Cancer Society to have an initial, or base-line, mammogram between the ages of 35 and 40.
Statistically, Boegner is a rarity.
Eighty-five percent of American women do not follow mammography guidelines set down by the American Cancer Society and several professional medical organizations. Besides the base-line mammogram, women should undergo periodic mammograms between the ages of 40 and 50 and annual mammograms thereafter, the cancer society advises. Screening or preventive mammography is also promoted by the American College of Radiology, the American College of Obstetricians and Gynecologists and the National Cancer Institute.
The Odds of Breast Cancer
If women undergo such screening mammograms they can increase the likelihood that breast cancer will be discovered in the earliest possible stages, studies show. One in 11 American women will experience breast cancer at sometime in her life, according to the American Cancer Society, and 40,000 women in the United States will die from it this year.
Despite the gloomy statistics, the well-publicized guidelines, and overwhelming evidence that mammography can help detect breast cancers even before a physician or a woman feels a lump, women don’t, as a rule, undergo the procedure.
Growing numbers of experts are now asking what may seem to be a simple question: Why don’t women undergo a 15-minute procedure that can save their lives? They’re learning that the answers are complex.
Many physicians are not referring women for mammography for a variety of reasons, surveys show. In a UCLA survey, non-referring physicians cited the perceived risk of cancer from the X-ray’s radiation (now an unrealistic fear, mammography proponents say) and the cost of the procedure (which averages $125 in the Los Angeles area) as reasons to forgo advising their patients to take the test.
“Women are not the ones resisting the procedure,” said Sarah Fox, an assistant professor of family medicine at UCLA who polled 900 women in three surveys to determine why they do not as a rule undergo the exam. The main obstacle, Fox said, is “referring physicians not referring.” Once a doctor refers a woman for mammography, Fox said, most undergo the procedure willingly.
A case in point is Maurine Hodges, 56, of Santa Monica, who recently made an appointment for her first mammogram. “It was never suggested (before),” she said, even though she has undergone gynecological exams fairly regularly.
“Doctors are not pushing mammograms,” said Dr. Philip Strax, a pioneer proponent of mass mammographic screenings and a New York City radiologist. “Maybe half of (all) doctors are not referring women for mammograms as they should.”
Other experts believe even fewer than half of all doctors are referring women for mammograms as advised. The UCLA survey of attitudes and referral practices of Los Angeles physicians toward screening mammography, for example, taken in 1984 by Dr. Lawrence W. Bassett, chief of the mammography section at the UCLA School of Medicine, showed that only 10.7% of 887 respondents followed American Cancer Society recommendations for annual mammograms for women 50 and older.
In that survey, general practice physicians were least likely to refer women, Bassett said, and surgeons were most likely. Physicians younger than 40 were more likely than older ones to refer according to American Cancer Society guidelines, he said. No significant differences were found in the referring practices of male and female physicians.
In another survey, conducted in 1982, most of the 509 New York family physicians polled said they did not recommend routine mammograms for their patients, citing radiation risk as their most common reason.
Better Equipment
The fear of radiation may have been justified a decade ago, say mammography proponents, when a mammogram delivered a much higher dose of radiation than what is delivered now by state-of-the-art equipment. But not today.
“The doses that people were worried about in 1975 . . . were about 25 times higher than those currently used,” said Dr. R. James Brenner, chief of the section of breast imaging at Cedars-Sinai Medical Center.
“There’s a small, purely theoretical risk of cancer from a mammogram,” said Dr. Richard H. Gold, a professor of radiological sciences at the UCLA School of Medicine. That risk, he said, is that 3.5 cancers per 1 million women per year, if each woman were exposed to 1 rad (a unit of radiation absorbed by tissue) of radiation in a mammogram. “The dose of most mammograms is less than half a rad now,” he said.
“The new equipment has extremely low radiation exposure,” said Dr. John Beeston, a professor emeritus of family and preventive medicine at the USC School of Medicine and a member of the board of directors of the American Cancer Society’s California division.
These days, state-of-the-art mammograms are taken by the film-screen method, using equipment specifically designed for mammography, or by the xeromammography method which electronically records the X-ray image on special paper. During the procedure a woman usually stands or sits while each breast is placed on a metal plate and compressed by a plastic device. The exam usually includes two X-rays--one taken from the top and one from the side--of each breast.
As the technique has improved, so has the accuracy. “Frequently, we can detect lesions less than one-quarter of an inch in diameter,” Brenner said.
“Mammography has a failure rate of about 10%--which in medicine is fantastic when you think about it,” said Dr. Samuel B. Haveson, the associate director of radiology at St. John’s Hospital and Health Center, Santa Monica.
In the last 20 years, two major studies have proven the value of screening mammography, proponents say. One, the Health Insurance Plan of Greater New York study, began in 1963 and offered patients annual screening by mammography and physical examination for four years. After seven years, women who underwent the screening had a 30% reduction in breast cancer mortality compared with the control group.
A more recent study, the Breast Cancer Detection Demonstration Project, co-sponsored by the American Cancer Society and the National Cancer Institute beginning in 1973, offered patients five annual screenings by mammography and physical examination. Mammography was found far superior to physical examination in detecting cancer, especially in its early stages.
A Difference in Mortality
The health insurance plan study, said Brenner, showed that mammography can make a difference in mortality in women 50 and older while the detection project established the worth of mammography in picking up cancers before they could be felt. Although there have been no long-term, controlled studies proving that screening mammography improves mortality rates in women younger than 50, Brenner said that “all long-range studies we have (of screening mammography) indicate similar benefits for women under age 50.” Studies patterned after the health insurance plan and detection project studies won’t be repeated in this country, Brenner believes, because of prohibitive costs and other factors.
Ongoing studies in Canada, Britain and Sweden, however, may prove screening mammography useful in reducing breast cancer deaths in women younger than 50, experts say.
Besides fear of radiation risk, physicians who don’t refer patients for screening mammograms often cite cost--an obstacle that some experts say may be a more legitimate excuse for nonreferral. In the Los Angeles area, a screening mammogram can cost as much as $200. Traditional fee-for-service insurance plans--such as Aetna Life & Casualty--tend to cover diagnostic mammograms, which are performed when breast cancer is suspected, but not screening mammograms. In the past few years, however, some companies have begun partial reimbursement of screening mammograms. Both types of mammograms are covered fully by some health maintenance organization plans. Screening mammograms aren’t covered under Medicare, but a bill to suggest such coverage is scheduled to be reintroduced in in the House of Representatives in January by Rep. Mary Rose Oakar (D--Ohio), her legislative aide said.
Some proponents of screening mammography believe cost is a relative issue. When Cedars-Sinai Medical Center initiated a low-cost screening mammography program, Brenner said, the requests for the procedure did not increase dramatically.
Overcoming Fear
Physicians who do refer patients for screening mammograms can’t be sure their patients will follow their advice. For some women, fear can be an overwhelming obstacle, Gold said. “(Some) women don’t want to know (the results of a mammography),” Gold said. “After all, we’re trying to find cancer before they know they have it.”
Some women say they avoid mammograms because they fear the procedure is painful. “There’s going to be some discomfort, even if a woman does not have tender breasts,” said Gold, “because the machine does have to compress the breast to get the best image.”
The discomfort a woman experiences, Gold said, may be intensified by her unfamiliarity with the procedure and the anxiety that sometimes results. “If a technician explains what’s going to happen, it can reduce anxiety,” he said.
Linda Boegner found the discomfort minimal. “To me it was less painful than giving blood,” she said. “It was almost as simple as getting a chest X-ray.”
As Fox sees it, increasing the number of women who undergo mammograms depends on changing the behavior of two groups. “One solution (to underutilization of mammography) is to change physicians’ behavior. Another is to teach women to ask for that referral. “Slowly but surely,” she said, “self-referral will be a trend.”
