Experts Urge More Breast Cancer Screening

But report says facility, personnel shortages impede progress

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HealthDay Reporter

THURSDAY, June 10, 2004 (HealthDayNews) -- More women need to have better access to mammograms, currently the best tool available for detecting breast cancer and saving lives.

That's the recommendation of U.S. government advisors, whose new report warned of a declining number of imaging centers and fewer personnel to interpret mammograms.

The report, Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis, was released Thursday by the Institute of Medicine (IOM) and the National Research Council of the National Academies.

"We're making a lot of progress against breast cancer, but still it's not enough," Dr. Harvey Fineberg, president of the IOM, said at a news conference. "Because there's no guaranteed cure, especially in the late stages of the disease, and because there's no way to prevent breast cancer, the best approach is to work on ways to detect breast cancer at the earliest possible stage, the stage when it is most treatable and curable."

The incidence of breast cancer continues to rise, with more than 200,000 new cases likely to be diagnosed in the United States this year and 40,000 women who will die of the disease. Although survival rates are improving, "there is still a significant gap in terms of lives we could be saving," stated Dr. Martin D. Abeloff, a member of the IOM committee that prepared the report and director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital and Health Systems.

The committee spent 18 months looking at which evolving technologies held out the most promise for improving early detection of breast cancer, and which approaches were likely to save the most lives today.

Several technologies are in development, but until they are validated experts need to stick with what's available. "We know mammography is not a perfect tool, but it's the best screening tool that we have right now," said Jean Lynn, a nurse who is program director of George Washington University's Breast Care Center and Mobile Mammography Program.

Unfortunately, access to mammography is being severely hampered by a number of factors, most notably an increasing shortage of facilities and of qualified personnel to read and interpret mammograms. "Facilities have been closing at a steady rate. Breast imagers are becoming an endangered species," Abeloff said.

According to Dr. Janet Joy, the study director and senior program officer at the IOM, the number of mammography facilities has declined 8.5 percent in the last four years and, between 2001 and 2003, the rate of closures doubled the number of openings. Fewer medical residents are choosing to go into this field, leaving training fellowships unfilled.

Why? Fear of malpractice suits (missed breast cancer diagnosis is the leading cause of medical malpractice, Abeloff said) and lack of money. Medicare pays slightly more than $82 for a mammogram, which costs a freestanding clinic about $87 to perform and a hospital about $105. "Roughly 40 million women are being screened, so the multiplier effect is enormous," Joy said.

The committee recommended that nonphysician technologists be trained to pre-screen or double-read mammograms under the supervision of a breast imaging specialist, a practice that has already been adopted in some European countries and even in parts of the United States. Other options include sending screening invitations directly to women and centralizing mammogram interpretations for more accuracy, both models that are being used in Britain and Sweden and at limited locations in the United States.

Specialists also need to learn how to identify the women who would most benefit from intensive screening. "The committee envisions a future, perhaps in the next decade, where breast screening can be stratified based on the level of risk," Abeloff said.

Finally, the perceived value of emerging technologies is based too much on "hype and marketing," Abeloff said.

One trial is currently comparing digital and film mammography in almost 50,000 women. "This will make statements about whether digital mammography improves breast cancer detection in population of average cancer," said Dr. Etta Pisano, an IOM committee member and chief of breast imaging at the University of North Carolina Hospital. Pisano is lead investigator of this trial.

In the meantime, efforts need to concentrate on how to improve what is already available.

"Mammography is the best breast cancer screening tool available now and in the near future," Abeloff said. "But this does not mean that we are stuck with mammography as it is."

More information

View the report at the Institute of Medicine.

SOURCES: Press conference with Harvey Fineberg, M.D., president, Institute of Medicine (IOM); Martin D. Abeloff, M.D., IOM committee member and director, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital and Health Systems; Etta Pisano, M.D., IOM committee member and Chief of Breast Imaging, Department of Radiology, University of North Carolina Hospitals; Jean Lynn, R.N., program director, George Washington University's Breast Care Center and Mobile Mammography Program; Janet Joy, M.D., study director, senior program officer, IOM; IOM report, Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis

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