Home » Malpractice » Breast Cancer »

Local mammography rates buck national trend

Oct 25, 2007 | Carol Harrison | The Eureka Reporter

A 30 percent decline in the number of mammograms performed in three Humboldt County hospitals is a misleading number for those concerned with reducing the toll of breast cancer.

The numbers from Redwood Memorial, Mad River Community and Jerold Phelps hospitals suggest Humboldt County is part of a national trend identified by a group of National Cancer Institute researchers in a study published online May 14 in Cancer.

Between 1987 and 2000, the percentage of U.S. women 40 and older who were getting regular mammograms grew steadily to an all-time high of 70 percent.

Lead researcher Nancy Breen and her group reported a leveling off between 2000 and 2003. By 2005, the overall mammography rates for women had dropped to 66 percent, which was 4 percent lower than in 2000.

Breen called the drop "disturbing."

What no one knows is why mammography rates declined. Complicating the analysis is how Humboldt County women figure into the national picture, with the March 2005 opening of Humboldt Radiology skewing the numbers for the area in general and St. Joseph Hospital in particular.

"The Humboldt Radiology numbers are key," Humboldt Community Breast Health Project's Sharon Nelson said. "Lower numbers elsewhere could mean people going to Humboldt Radiology. They had much better equipment and many local physicians were referring patients there."

The widely publicized split from St. Joseph Hospital ended in December 2006, but Humboldt Radiology appears to have absorbed the decline posted from the other four hospitals and convinced another 5,000 to have mammograms done locally.

"If the numbers are accurate, then I do think that the superior equipment purchased by Humboldt Radiology was a huge draw for both patients and doctors," nationally recognized breast cancer expert Dr. Ellen Mahoney said.

Another factor: a push by the Humboldt-Del Norte Independent Practice Association as part of the pay-for-performance effort that rewards physicians for getting their patients to undergo basic screening. In 2006 pay-for-performance numbers, HDNIPA and its 5,000 patients topped the state with 85 percent of those eligible for a mammogram getting one.

"It's about creating a social movement and creating a focus in clinicians on the importance of mammography," HDNIPA Medical Director Alan Glaseroff said. "Our push, Humboldt Radiology's equipment - 5,000 more is possible."

The rough total of 15,500 mammograms for 2006 amounts to roughly one out of every two Humboldt County women over the age of 40. The 50 percent who didn't get one are passing on what the American Cancer Society calls the single most effective method of early detection of breast cancer.

Mammography is a low-dose X-ray procedure that requires squeezing the breast between two plates to generate an image of the internal tissue.

On average, the ACS reports mammography will detect about 80 to 90 percent of breast cancers in women who display no symptoms.

Treatment is more successful when cancer is discovered early. The ACS Web site reports five-year relative survival rates at 100 percent for women with Stage 0 and Stage 1 cancers.

The rates drop to 92 percent for Stage IIA, 67 percent for Stage IIIA and 20 percent for Stage IV.

"The information about why we need mammography has been around a long time," said Linda Erickson of Mad River Community Hospital. "It's something else (behind the national decline in those getting tested). People may be discouraged they're still getting pressed. It can be an uncomfortable thing for some.

"People are more aware of radiation, wondering if radiation itself can be causing an increase in breast cancer. They're asking, ‘Is any radiation good?'"

The Humboldt Community Breast Health Project lists the risk of radiation exposure as the No. 2 reason women over 40 fail to get an annual mammogram.

Mahoney said a round-trip airline flight across the U.S. exposes women to the same amount of background radiation in a year as a four-view mammogram. Both exposures, she said, are negligible.

Mahoney also said studies have shown flight personnel exposed to about 320 times the amount of radiation in a year as is present with a single mammogram have shown no excess cancer risk.

"Just living 900 feet above sea level exposes one to more excess radiation in a year than diagnostic tests like mammograms," she said. "We just don't see people factoring in radiation exposure as they decide to live on Fickle Hill or Greenwood Heights, and we don't see people planning their vacations to avoid long-haul flights especially during times of solar flares."

Nelson, patient care coordinator for HCBHP, said, "The biggest obstacle to screening is financial. That's what (California's) Cancer Detection Program is supposed to be addressing with free annual mammograms and Pap smears for those who meet age and income guidelines."

In a survey of the 319 women who signed up for last year's free mammogram drawing at the American Cancer Society, one-third of respondents said they either couldn't afford it or didn't know how to access financial help to get one done.

"The number of women who have lost their health insurance in recent years is enough to account for the difference," Mahoney said. "You have to keep in mind the incidence of breast cancer is going down in recent years, and you don't find early breast cancer unless you do a mammogram."

Mahoney said only mammography can reveal tiny flecks of calcium, a metal, which shows up well on X-rays because of its brightness.

Almost everyone has some calcium in their breasts because it is attracted to places of inflammation and injury, she said.

"When the calcium is in a particular pattern, in the shape of a branching breast duct, there is a chance that it represents an early cancer, possibly even one that has not yet made it out of the duct or lobule where it started and into the surrounding breast tissue," she said. "When detected at this stage, it is curable."

The American Cancer Society's Facts & Figures 2007-08 reports the breast cancer death rate continues to fall by 2 percent a year, which it has done every year since 1990.

"There are also women who believe they don't have a family history and don't need to be screened, which is incorrect," Nelson said. "Or they had a normal mammogram and believe they don't need to come every year. They need them annually to look for changes."

Another possibility: fear.

"We're all queens of denial," Erickson said. "If you get one, you have to find out. That's frightening."

Radiologists are also frightened, leading some rent-a-doc radiologists to announce ahead of time that they don't do breast imaging.

"Failure to diagnose breast cancer is now the leading type of malpractice lawsuit," Mahoney said. "A survey in the journal Radiology in 2005 reported that half of the radiologists responding had been a defendant in a lawsuit. Are half of our radiologists negligent? Highly unlikely. But breast cancer is a common disease, and a very emotional one."

Mahoney said lawsuits, low insurance reimbursement rates and a bevy of regulations and inspections all contribute to fewer physicians becoming mammographers.

"The conclusion is reached by many experts that if every woman who should be screened presented for screening, we couldn't handle the demand," she said.

Humboldt Radiology is a case in point.

"We're doing them all day, every day," a technician said last week. "About 45 a day, one every 10 minutes."

The researchers from the National Cancer Institute used several years of data from the National Health Interview Survey to identify the decline as a national trend.

The declines were across the board and included subgroups that had traditionally shown high rates of mammography use: white women, the well-educated and those with private health insurance.

Breen's study revealed mammography use had dropped from 79 percent to 72 percent among women 50 to 64. That age group posts the largest number of breast cancer cases in the U.S.