Doctors admit mammography isn't the perfect diagnostic tool. Sometimes, false positives result in unnecessary biopsies and about 30 percent of malignant tumors are not discovered, particularly in younger women.
But doctors maintain that these screenings are still the best thing going to detect breast cancer early, especially for women over 50.
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Age & risk
The older a woman is, the greater her chance of getting breast cancer, according to the National Cancer Institute.
By age 30: 1 out of 2,212
By age 40: 1 out of 235
By age 50: 1 out of 54
By age 60: 1 out of 23
By age 70: 1 out of 14
By age 80: 1 out of 10
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The National Cancer Institute estimates that last year, 192,200 women were diagnosed with breast cancer, and 40,600 died from it.
And doctors say early detection leads to early treatment, which can save lives.
At least that's the conventional thinking.
But that widely held belief came under question last October when the British medical journal The Lancet published a review of mammogram studies that two Danish researchers had conducted.
Their findings, that science hadn't proved mammograms save lives, confused and frightened women and brought a whirlwind of protests from the medical community, which, for years has maintained that, yes, they do.
As the dust settles, doctors are taking a harder look at the researchers and their methodology.
"Those kind of things make headlines because they generate controversy, but I think the data says just the opposite," said Dr. Victor Vogel, director of the Comprehensive Breast Program at Magee Womens Hospital/University of Pittsburgh Cancer Institute.
"Those researchers somewhat selectively reviewed the literature."
He cited an article published last May in the Journal of Cancer, which updated the ongoing Swedish mammogram study that began 30 years ago.
"We used to say mammography can reduce the risk of dying by about 30 percent, but the new data from the Swedish study says it's closer to 60 percent, and most of that data is confined to women over 50," he said.
For younger women however, the jury is still out. In 1996, the National Institutes of Health convened an expert panel to determine the benefits of mammography on women age 40 to 49.
"The panel came to the unfortunate conclusion that there was no evidence of the benefit," Vogel said. "That doesn't mean there is no benefit, the fact is it's just never been adequately tested.
"But in women over 50, where two-thirds of breast cancer cases occurs, the data is unequivocal that mammography saves lives," he said. "I think you have to be very, very careful about looking at one or two studies the way those researchers did and drawing conclusions."
Other national experts have also questioned the validity of the Danish review, pointing out that five of the seven large studies they examined clearly showed that mammograms save lives.
And the question of motive has also been raised.
"I wonder about their agenda," Vogel said. "Maybe they are trying to save costs, and that is a question that has to be carefully evaluated, because even with imperfect data, it has been shown that it is actually beneficial on cost-benefit basis to do them."
And cost is a mighty issue in mammography.
The National Cancer Institute estimates that 31 million mammograms are performed every year at an average cost of $100 each. This represents a national expenditure of $3.1 billion.
But government and private insurance reimbursements have not kept up with costs. The monetary loss has been blamed for everything from mammography centers closing to a shortage of radiologists and technicians.
Last spring, hospitals were hopeful for relief after federal legislation was proposed to increase Medicare reimbursements. But the Sept. 11 attacks stalled those bills.
While the legislation is still being considered, cuts went into effect on Jan. 1.
Last year, Medicare paid $76 for a screening mammogram. Since the beginning of the year, the rate has been cut to $70, while the hospital cost is $120, said Lance Trott, manager of reimbursement at Magee-Womens Hospital.
A diagnostic mammogram costs hospitals more than $200, but Medicare reimburses $60, a decrease from the $63 it paid in 2001, he said.
"If you don't cover the cost, it's clear that radiologists will do something more lucrative," Vogel said.
And where Medicare leads, private insurance follows, said Dr. Jules Sumkin, chairman of Magee's Department of Radiology.
"What will happen is some facilities will close and others will cost shift," he said. "For example, the radiologist we hired at Magee is doing primarily mammography, but they will have to be subsidized by other areas in radiology, because it is our mission to do them."
Another major issue is liability.
Radiologists miss up to 30 percent of breast cancers, especially in younger women who have denser breast tissue. While new tools, such as computer aided diagnostics, can increase cancer detection by 19 percent, they are more costly.
"This is one of the most litigated areas," Vogel said. "Even the best radiologist using the best equipment and the best technique can occasionally miss a cancer, and that doesn't mean anyone has been negligent. That just means technology is limited, but that is when people will sue."
"For these reasons, there is a national shortage of radiologists who are willing to do mammography. It's a very difficult situation."
For the consumer, this means long waits for appointments.
Last year Magee conducted 18,500 diagnostic and 44,000 screening mammograms making it one of the busiest in the country.
But this resulted in long waits for appointments. So Magee expanded its hours and hired two radiologists and additional technologists, Sumkin said.
Concentrating on diagnostic mammograms, Magee cut the wait from 29 days in April to 12 days in December. For screenings, the wait dropped from 36 days in April to 28 days in December.
"What amazes me is, despite all the reimbursement issues, mammography remains pretty much on the front burner," Sumkin said. "There is a lot of technology going on, a lot of research and interest in it, but how long will that last? I continue to believe this has to be fixed on the federal level."
Vogel agrees, and said he will continue recommending annual mammograms for women over 40 until science definitively proves there is no benefit.
"And I do that understanding there will be unnecessary biopsies and surgeries that otherwise would not be done," he said. "But I am not willing to allow 15,000 women a year to die when the data suggests that those deaths can be prevented."
