In the past 3 years, the number of mammography centers in the United States dropped nearly 10%, from about 10,000 to 9,100, according to data from the U.S. Food and Drug Administration. Applications for breast-imaging fellowships have fallen off 75% in some medical centers. A 2003 survey of radiology residents found that 87% consider mammography more stressful than any other type of imaging, largely because of its low reimbursement rates coupled with its high malpractice risk. Some researchers say that all of these factors mean that the medical field will soon face a critical shortage of radiologists to read mammograms.
"We're not bringing new people on board," said Judy Destouet, M.D., a Baltimore specialist in breast imaging and chair of the American College of Radiology's Mammography Accreditation Committee. "No one's going to replace us."
The apparent exodus from breast imaging comes during a booming demand for mammography. Media campaigns promoting mammograms for women ages 40 and older have boosted the percentage of women getting the screening exam annually to more than 60%. The number of women between the ages of 40 and 84 is expected to increase over the next two decades from 64.6 million to 77.4 milliona trend that will likely increase the demand for mammography.
Specific data on patients' wait times or on nationwide mammogram facilities are hard to come by. A study published in the May issue of Radiology is one of the few that examine such access. The researchers found through a survey of 45 mammography centers that wait times ranged from 1 to 8 weeks for screening mammograms and less than 1 week to 4 weeks for diagnostic mammograms. A committee that studied access in 2004 for the Florida Legislature found that 15 of the state's 67 counties had no breast-imaging facilities and 15 counties had only one.
Unrealistic Expectations
One turnoff of the field is mammography's high malpractice risk, which stems from a conflict between the exam's ambiguity and the public's expectations. Radiologists detect an average of 70% of cancers on mammograms, according to the American College of Radiology.
"Many women were given the simple message that if you got your mammogram, nothing would happen to you," said Robert Smith, Ph.D., director of cancer screening for the American Cancer Society. "It's an enormous challenge to explain to people that there are no guarantees."
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Smith's suggestion to improve the high malpractice risk is a no-fault system modeled after the National Childhood Vaccine Injury Act of 1986. The act creates a federal program to compensate children injured by childhood vaccinations.
"The no-fault model would encourage radiologists to specialize in mammography," Smith said. "Women need to depend on the fact that radiologists are practicing at the top of their game."
The second major obstacle to attracting radiologists to breast imaging is low reimbursements. Medicare pays only about $88 per mammogram, a fraction of the rate paid for MRIs, CT scans, and other imaging techniques that are less likely to land radiologists in court. The American College of Radiology cites financial problems as the most common reason breast-imaging centers close.
"We heard of facilities closing when they had high volume but couldn't make ends meet," Smith said. "We have supported changes to increase reimbursement."
Yet another factor driving radiologists away from mammography is its low-tech nature. Many radiologists simply find MRI, CT scanning, interventional angiography, and other new technology more stimulating than mammography.
"Generally, radiologists are not interested in breast imaging," said Priscilla Butler, senior director for breast-imaging accreditation programs at the American College of Radiology. "The high-tech stuff is much more interesting."
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Some breast cancer activist groups contend that the problem isn't a shortage of mammographers but rather a needlessly high mammogram demand. That's the point of view of Maria Carolina Hinestrosa, executive vice president of programs and planning for the National Breast Cancer Coalition.
"We don't believe mammography is indicated for women in their 40s," Hinestrosa said. "The ultimate goal of screening programs is to reduce mortality from a disease, and the decrease in mortality of women in their 40s is questionable."
Some studies support her claim. One, conducted 4 years ago at Denmark's Cochrane Institute, found that overuse of mammography leads to false positives and painful biopsies, particularly in younger women. Raising the recommended starting age for regular mammograms, though, is an unlikely solution to the mammographer shortage. Despite its own finding of questionable benefits, the U.S. Preventive Services Task Force (USPSTF) currently recommends that all 40-year-old women start getting mammograms every 12 years. The Susan G. Komen Breast Cancer Foundation, American Cancer Society, and American College of Radiology all advise women to start annual mammograms at 40.
One form of relief, suggested in the 2004 report, "Saving Women's Lives: Strategies for Improving the Early Detection and Diagnosis of Breast Cancer," by the Institute of Medicine is to train nonphysicians to read mammograms. (See News, Vol. 96, No. 16, p. 1200.) They would work under the supervision of a breast-imaging specialist, prescreening or double-reading images. Preliminary studies in the United Kingdom suggest these technicians' accuracy is comparable to that of radiologists.
A more likely scenario that is already being used with other types of x-rays is teleradiology, or sending digital breast images to specialists at other, sometimes distant facilities.
"I think that in the future, there will have to be some mechanism in place for remote reading of mammograms," Destouet said.
Many researchers and advocates hope that two forthcoming reports will bring mammography to the attention of Congress. One is being conducted by the Institute of Medicine and was scheduled to be released May 23, after this issue of the journal went to press. Congress commissioned the IOM report and a second report from the Government Accountability Office last year to see if changes needed to be made in the Mammography Quality Standards Act, which will be up for reauthorization in 2007. The Act was first passed in 1992 to expand access to mammography and to ensure quality at all breast-imaging facilities. Under the act, mammography facilities must meet specific federal standards and pass annual inspections.
"It's time to take a step back and see if changes (to the Act) are needed," said Sharyl Nass, Ph.D., director of the IOM study. "Congress is aware of recent reports that access is an issue." Both studies will be published this summer.
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