Declining mammography rates portend potential preventive care crisis

Breast cancer screening rates among young premenopausal women are declining, according to a study on mammography use from the Centers for Disease Control and Prevention. Mammographers worry that the trend could lead to the erosion of screening services and of preventive care in general.

The clinical literature documented a dramatic increase in the use of mammography screening during the 1990s. Recent reports have linked this utilization growth with the decline in breast cancer incidence and mortality rates observed until 2004. The same reports also note a decline in mammography use from 2000 through 2005, however, causing concern about eventual mortality rate hikes.

The latest CDC report, published in the February issue of the American Journal of Roentgenology, provides evidence that a troubling trend may be at hand. Researchers analyzed mammography screening utilization rates for each U.S. state in correlation with its respective breast cancer incidence rates. In two-thirds of the states, investigators saw a slight decline in mammography use between 2000 and 2006.

With the exception of Tennessee, every state saw a breast cancer incidence rate reduction during the 2000-2006 period, while 17 had a slight increase in mammography screening rates. Researchers also discovered a decline in screening rates, however, in 34 states and the District of Columbia. The overall screening utilization rate among women age 40 or older decreased slightly or remained stagnant, according to the study.

A commentary that also appeared in the February AJR by Dr. Ruth C. Carlos, an associate professor of radiology at the University of Michigan, warned that declining mammography screening rates could lead to lost opportunities for cancer prevention for a whole new generation of women, not only for those who are or soon will be eligible for screening.

Data show that health insurance coverage rates are falling, the number of low-premium/high-deductible plans is increasing, and the number of breast imaging facilities is declining. In combination, these factors are contributing to the decline, Carlos said. Less screening will likely affect already underserved populations such as the urban poor and minorities. It may also lead to the relaxation of preventive care standards, which could in turn undermine prevention of other conditions that affect women, such as cervical cancer.

"Fewer women undergoing screening means fewer models for appropriate preventive behavior by their children. Once learned, health behavior is difficult to change," Carlos said.

Mammographers share the concern. Many premenopausal patients in their 40s may not be returning for their annual screening mammograms, according to Dr. Stamatia Destounis, a radiologist at the Elizabeth Wende Breast Clinic in Rochester, NY.

"In our practice, we have a computerized system that creates a recall card for patients for their yearly follow-up screening appointment. We have noticed a trend in the late 1990s from 94% returning for their follow-up yearly mammograms to 89% more recently," she told Diagnostic Imaging.

The system is not exact science and cannot reflect the fact that patients may have moved out of the area or to another screening facility. lLocal private and government organizations that promote breast cancer screening or support women with inadequate or no health insurance, however, have seen funding minimized or cut. As a result, many women are being forced to cut corners, Destounis said.

"In our area in upstate New York, just like our entire country, the unsettling economy has made women consider not maintaining their health insurance or going with insurance that may not cover screening exams," she said.

Years spent educating patients about the benefits of screening mammography and early detection could be lost, as well as the ability to provide the exams, Destounis said.

"As a radiologist in a freestanding breast clinic, I worry that eventually I will be out of a job if patients don't come for their screening exams, as the clinic will not be able to afford to stay open," she said.

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