Breast Cancer Survival Guide, Part 1

Common Problems

Part of the reason may be that fewer physicians refer women for breast cancer screening, possibly because there is new debate about how often it is needed. The American Cancer Society still staunchly advocates annual mammograms for women over 40, but the American College of Physicians suggests many women could wait until age 50. However, many centers have shut down for lack of money, not patients. Insurance firms and Medicare generally pay very low reimbursements to breast-imaging centers. Other centers have scaled back on services to balance their budgets. All this can even make it more difficult to get follow-up diagnostic tests, like the ultrasound that revealed ABC news anchor Robin Roberts had cancer after she felt a lump in her breast.

The result? Women lacking symptoms who just want screening may wait up to four months -- even in big cities like New York -- and may have to travel 60 miles or more in rural areas, according to a 2006 survey by the U.S. General Accountability Office.

What you can do: Make appointments well in advance. It helps to book them around an event -- your birthday or an anniversary -- and set the next one at the end of your current appointment. A year goes by quickly, and it's easy to lose track of how long it's been. "Treat yourself to a lunch with friends afterwards," says Constance Lehman, MD, PhD, vice chair of radiology at the University of Washington and the Seattle Cancer Care Alliance. That way, you'll be less tempted to cancel.

Fewer physicians specializing in breast cancer has caused another crisis. The stress of the work and fear of malpractice claims -- missed or delayed diagnosis of breast cancer is a leading cause of medical malpractice lawsuits -- are to blame. "Breast imaging in general is subject to intense oversight," says Mark Helvie, MD, a professor of radiology and director of breast imaging at the University of Michigan. "This field is difficult and stressful." In a 2005 Society of Breast Imaging survey of 575 breast-imaging centers nationwide, more than 55 percent reported their doctors had been sued, half said threat of suits made it harder to fill jobs, and 29 percent had radiology vacancies.

What you can do: Try university medical centers with breast-imaging radiology fellowships, which may be better staffed.

Digital mammography is up to 15 percent more sensitive in detecting cancers in women under age 50, and among women of any age with dense breast tissue, but the machines that do the test are in alarmingly short supply. Cancer in younger women tends to be more aggressive, making early detection critical.

The percentage of imaging centers offering digital mammography has more than tripled since 2005, from 6.3 percent to 20.4 percent, according to the American College of Radiology. Still, four out of five breast-imaging facilities in the country don't offer it.

The situation is even worse for breast MRIs, available at just one in eight imaging centers. MRIs cost about $1,000 (compared with $50 to $150 for film mammograms and $125 to $225 for digital). They've proved effective in monitoring high-risk women, who are urged to get a yearly MRI and mammogram, usually starting at 30.

What you can do: Travel to a nearby city. Centers that have digital mammography are more common in urban areas, says Marisa Weiss, MD, a Philadelphia oncologist and president of Breastcancer.org. University hospitals are another option. And check the list of centers with Mammography Quality Standards Reauthorization Act technology found at www.fda.gov/cdrh/mammography/certified.html.

All the high-tech breast-imaging facilities in the world will not help if you don't make an appointment. Elizabeth Edwards admitted that she hadn't had a mammogram for some four years before finding her breast cancer lump. "We may be victims of our success," says Carol H. Lee, MD, a professor of diagnostic radiology at the Yale University School of Medicine and chair of the breast-imaging commission of the American College of Radiology. "Because we've made such remarkable progress, women may see breast cancer as less of a threat. We could see a reversal of the gains we've made over the years." And all the emphasis on high-tech tools may have devalued the much more available and still lifesaving film mammogram: "They're still the best thing we have for spotting cancers early," says Dr. Pisano, whose research found that both film and digital mammography have similar accuracy rates, though digital has an edge in finding breast cancer in women under 50 and those with dense breasts.

What you can do: Stop making excuses, even if you must wait longer than you should or drive farther than you'd like to get tested.